Throughout this series on women’s reproductive care, we often identify women as people with biologically-female anatomy, such as a uterus, a vagina, and ovaries. However, we acknowledge that people with this anatomy identify as other genders, that having this anatomy does not necessarily mean a person is a woman, nor is it a prerequisite for being a woman.
Maybe you benefitted from a comprehensive sexual health program in school, where you were taught about different diseases and how to prevent contracting and spreading them.
Maybe you had parents willing to speak to you about sexually transmitted diseases, possibly going as far as providing you with the means to protect yourself.
Or maybe you had no formal education at all about STIs and learned about them as a result of unprotected sex.
No matter how you learned about STIs, ask yourself these questions: did your education make you feel that STIs are something to be ashamed of? That STIs only affect “dirty” people with poor morals? Did you feel equipped with enough information to confidently protect yourself in sexual relationships?
Even today, young people in the U.S. are woefully uninformed about STIs. According to Planned Parenthood, only 29 states mandate some form of sexual education. For the remaining 21 states, school districts are allowed to teach “abstinence-only” education, meaning that, because young people should not be having sex anyways, they are not given information about preventing unintended pregnancy or STIs.
But the truth is, young people are having sex. According to the CDC, over half of U.S. teens have had sex by the time they turn 18. If this is the reality, why are school districts given the right to decide when it is okay for a young person to start having sex? Is it once they graduate high school? Once they get a steady job? Once they get married? Once they want to have children?
It is well-documented that abstinence-only sex education programs do not lower adolescent sexual activity or prevent unintended pregnancies. However, they do prevent young people from knowing how to take care of themselves as sexual beings. Abstinence-only programs increase feelings of shame and mystery around sex, leaving young people already grappling with the complexities of human sexuality to wonder why they feel sexual urges and what to do about them.
Women and girls are particularly disserved by the U.S.’s current thinking about sexual education and sexuality. As we will explore later, women are more susceptible to STIs and suffer more serious consequences from untreated STIs, than men. In addition, young women are expected to abstain from sex more than young men and are judged more severely if they choose to become sexually active. Compounding this inequity is the fact that we live in a hypersexualized culture, where women are regularly objectified for heterosexual men’s benefit, but also chastised for embracing sexuality on their own terms. American society expects women to be prudent while also consuming women as sex objects – this creates an unfair and unsafe terrain for women navigating their own sexuality and sexual health.
What Are STDs/STIs and How Do They Spread?
Sexually transmitted diseases (STDs/STIs) are infections contracted and spread through sexual contact. Sexual fluids, such as vaginal secretions, semen, pre-ejaculate, anal secretions, saliva, and blood are the medium through which many STIs are transmitted. Accordingly, any contact with these fluids can put someone at risk for contracting an STI. In addition, STIs can be spread through sex between any two people, regardless of gender.
Contrary to popular belief, STIs can be spread through all types of sex, including: vaginal, anal, oral, and manual. Different types of sex put a person at risk for different STIs. According to Planned Parenthood:
Unprotected vaginal or anal sex can spread: chlamydia, gonorrhea, syphilis, HIV, herpes, HPV/genital warts, hepatitis B, public lice (crabs), scabies, and trichomoniasis.
Unprotected oral sex can spread: herpes, HIV (unlikely but possible), syphilis, gonorrhea, chlamydia, HPV, and hepatitis B.
Unprotected genital skin-to-skin contact can spread: herpes, HPV/genital warts, syphilis, public lice (crabs), scabies, and molluscum contagiosum.
STIs, however, do not need to be shameful, scary, or cause for guilt. In fact, nearly every sexually-active person will contract an STI at some point in their lifetime. Most STIs are mild and are very treatable or can be cured entirely. Importantly, people with identified STIs can still enjoy fulfilling sex lives if taking the proper treatments and precautions.
The North Carolina Department of Health and Human Services identifies 22 major STDs/STIs, the most common of which are: HPV, chlamydia, gonorrhea, syphilis, trichomoniasis, and genital herpes (HSV I or II). Four of these diseases (chlamydia, gonorrhea, syphilis, and trichomoniasis) can be cured and the other two are treatable.
The single most important factor in treating STIs, however, is identifying the disease as early as possible.
If you experience sores or bumps around your genitals or buttocks, atypical discharge from your genitals, burning or pain during urination, itching or burning around your genitals, or flu-like symptoms, these could all be signs of a sexually-transmitted infection. The single best thing to do is visit a doctor or nurse, explain your symptoms, and express concern for STDs/STIs. All STI tests and exams can be completed in a matter of seconds to minutes, with results delivered quickly afterwards.
How Do I Prevent STD/STI Transmission?
As any physician will tell you, the safest sex is no sex. However, this is an unrealistic option for the majority of people. Sex is a natural and often beautiful part of life and should be enjoyed (safely!) by consenting adults.
Some types of sex are safer than others. According to Planned Parenthood, low-risk sexual activities include kissing, using sex toys with a partner, and grinding. Higher-risk sex includes vaginal, anal, and oral sex, each becoming greatly more risky without a barrier.
The best (and only!) way to protect against STIs if you are having sex? Using a barrier every time. Barriers can be traditional condoms, internal condoms (worn inside the vagina), dental dams (for oral sex on a vulva/vagina), or latex/nitrile gloves (for manual sex). Using barriers prevents the transfer of sexual fluids and also limits skin-to-skin contact, protecting against many STIs.
In addition, lubrication should be used in tandem with condoms to further protect against STIs. Latex condoms can contribute to friction, which in turn can cause micro-abrasions in genital tissue. These tiny cuts make a person more susceptible to contracting an STI. Lubrication limits the development of these abrasions and can make sex more comfortable.
Condoms and other barrier methods should be worn during sex unless you are absolutely certain of your STI status (meaning you and your partner were tested for a full spectrum of disease recently, and neither of you have engaged in sex with a different partner since being tested.) Importantly, people must adhere to correct condom hygiene for the best protection:
Store condoms in a cool, dry, dark place; check the condom’s expiration date and the package for holes or tears before use; place the condom on an erect penis before sex; never use two condoms at the same time; remove the condom promptly while your partner still has an erection; use a new condom every time you have sex (even if these times happen close together); use a new condom if switching between different types of sex (such as from anal to vaginal).
The Most Common STDs: Chlamydia, Gonorrhea, and HPV
According to the 2019 North Carolina STD Surveillance Report, chlamydia is most common STD diagnosed in North Carolina and in the U.S and cases have been on the rise for years. In 2019, over 679 people out of 100,000 tested positive for chlamydia. Chlamydia is more common in young people, with 15-29 year-olds comprising 83.6% of people diagnosed. Likely due to increased testing, women experience higher rates of chlamydia (66% in women and 33% in men).
Chlamydia is caused by a bacterium that can enter the body through any mucous membrane, such as the skin inside the vagina, on the penis, in the mouth or throat, and around the eyes. Once someone is infected, they may experience symptoms such as strange discharge or painful urination. However, the most common symptoms are no symptoms at all. This makes it very hard to detect and treat chlamydia without routine testing.
If chlamydia goes untreated, severe damage to the reproductive tract can occur. Unfortunately, women with untreated chlamydia can develop Pelvic Inflammatory Disease (PID), which can lead to infertility. The chlamydia-causing bacteria can travel and reproduce inside a woman’s uterus and fallopian tubes, causing inflammation and scarring which can later make conception and pregnancy difficult, or harm the fetus or newborn infant.
Luckily, if chlamydia is detected early, it can be quickly treated with antibiotics, and cause no lasting harm to a woman’s reproductive tract.
Gonorrhea is similar to chlamydia in that it is very common, occurs more often in younger people, causes similar symptoms, and can lead to great reproductive harm. The 2019 NC STD Surveillance Report states that 254 people out of 100,000 were diagnosed with gonorrhea. In addition, 15-29 year-olds comprised 69% of the people diagnosed. Unlike chlamydia, gonorrhea appears to infect women and men at similar rates, at 53% and 47% respectively.
Gonorrhea is also caused by bacteria that can enter through the body’s mucous membranes. An infection may result in genital discharge or painful urination, however, a woman or man may experience no symptoms whatsoever. Untreated gonorrhea can also cause PID, which can jeopardize a woman’s ability to conceive or gestate in the future.
The gonorrhea-causing bacteria has begun to develop antibiotic resistance, making it an increasing threat to public health. This means that the medications health care professionals rely on the treat gonorrhea may no longer work on the disease. Accordingly, North Carolina imposes a strict 1-day policy for health care settings to report new cases of gonorrhea, so that further spread can be limited.
In addition, according to the NC Department of Health and Human Services, both chlamydia and gonorrhea infections can make a person more susceptible to HIV. This is because active infections bring a higher concentration of immune cells to the genital area, which are the cells targeted by HIV.
Human Papilloma Virus (HPV)
HPV is the most common STI of all. In fact, it is so common that nearly every sexually-active adult will encounter the virus at some point in their lives. The CDC estimates that 14,000,000 Americans become infected by HPV every year. Sound scary? It does not have to be.
Sexually-transmitted HPVs belong to the same family of viruses that cause benign warts, the kind we get on our elbows or the bottoms of our feet. According to the CDC, over 40 of the known 200 strains can be sexually transmitted. Many strains cause no symptoms whatsoever in women and men, and can be attacked and cleared by the human immune system, just like viruses that cause the common cold.
However, some strains of HPV can be more bothersome or dangerous. According to Planned Parenthood, 2 strains of HPV can cause genital warts and at least 12 known strains can lead to reproductive cancers, such as cancer of the cervix, vulva, vagina, penis, anus, mouth, or throat.
The good news is that HPV can be prevented entirely through vaccination, treated if symptoms do arise, and worked around if an HPV-positive person wants to have sex.
In 2006, the FDA approved the first-ever vaccine to protect against HPV contraction. Nowadays, children ages 11-12 can get two doses of the HPV vaccine, effectively protecting them from ever contracting or transmitting the virus. Three vaccines are currently available (Gardasil, Gardasil 9, and Ceravix), all of which protect against the strains that cause most cancers.
The HPV vaccine has been hugely successful. According to Duke Health, vaccine usage has decreased the rate of HPV-driven cervical precancers by 40% in vaccinated women, decreased cancer- and genital wart-causing HPV infections by 88% in teen girls, and decreased cancer- and genital wart-causing HPV infections by 81% in adult women. In addition, the vaccine does not cause any significant side effects. By all accounts, this has been a smashing success.
As Jennifer Howell, MD, a pediatric and adolescent gynecologist at Duke Health observes: “this vaccine is an anti-cancer vaccine. It has the potential to completely eradicate certain cancers.”
If a person does contract HPV, options are available to manage symptoms of genital warts and prevent cancers. Genital warts, while functionally harmless, can be removed by a doctor or nurse through a simple, outpatient procedure. For women at risk of developing HPV-related cervical cancer, there are two procedures, cryotherapy and Loop Electrosurgical Excision Procedure, to remove precancerous cells from the cervix and stop cancer in its tracks.
STIs as a Perpetrator of Inequity: Gender Bias and Poverty
Interestingly, STIs are not only a public health concern, but also reflect and perpetuate ingrained societal inequities such as discrimination against women and damaging wealth distributions.
The CDC identifies 7 major ways how STIs affect women differently than men, including: women being more susceptible to contracting STIs, women being less likely to display symptoms of STIs, women’s anatomy making STI detection more difficult, and STIs complicating a woman’s future fertility and pregnancies.
While the vagina’s moist and delicate skin serves an important function, it is easier for bacteria and viruses to penetrate this tissue than the skin on a penis. In addition, the symptoms of STIs in women: painful urination, odd discharge or odor, irregular bleeding, or itching, mirror the symptoms of non-sexual diseases which women experience, such as UTIs or yeast infections. Given the symptom overlap, dangerous STIs can be “mistakenly written off as a typical female annoyance.”* Not only is this dangerous for women, but it reinforces a medical narrative that places less emphasis on women’s pain and discomfort than men’s.
STIs can also affect a woman’s reproductive future much more seriously than a man’s. While STIs in men are unlikely to cause infertility, chlamydia and gonorrhea are the two leading causes of infertility in the U.S. and beyond. Consider this with the fact that a woman’s value is often tied to her reproductive capacity, and you can sense the unfair burden which STIs place on women.
HPV, in particular, highlights the ways in which STIs can unequally affect women versus men. While HPV is likely equally present in women and men, HPV-driven cancers disproportionately affect women. According to the National Cancer Institute, HPV causes virtually all cervical cancers, 75% of vaginal cancers, and 70% of vulvar cancers. On the other hand, HPV causes 60% of penile cancers. Not only is HPV the cause of more types and higher percentages of reproductive cancers in women, but these HPV-driven cancers are also significantly more common in women. In fact, according to a 2021 American Cancer Society report, there were 7 times more reported cases of cervical cancer than penile cancer, nearly all of which were caused by HPV alone.
In short, STIs infect women more readily, are harder to sense and detect, are often mistakenly misdiagnosed, and lead to more severe reproductive consequences than in men.
Poverty and Race
In addition to gender bias, STI transmission and prevalence also reflect grave socioeconomic differences influencing access to health care. According to the 2019 NC Surveillance Report, “poverty and large gaps in wealth distribution” are the likely causes of observed differences between STI rates in some racial and ethnic communities.
For example, in North Carolina, people identifying as Black/African American report higher rates of chlamydia and gonorrhea than people identifying as white. This is likely due to unequal wealth distributions between Black and white people, with Black people disproportionately represented in those below the poverty line. As the report explains, those “who cannot afford basic needs may also have trouble accessing quality sexual health services, and may have had experiences with the health system that discourage [accessing] testing and care.”
The graph below adds the visual to this reality. As you can see, the blue and green bars corresponding to rates of chlamydia and gonorrhea steadily increase as wealth decreases, reinforcing the fact that income greatly influences health outcomes.
Sex, STIs, and Shame: What’s Wrong with the System?
So what have we learned? Most adults will contract an STI in their lifetime, the most common STDs are curable or very treatable, and while some STIs are quite serious, most do not have to be. The most important factor for the successful treatment of any STI is identifying the infection as early as possible.
Comprehensive sexual education, however, continues to evade American youth. More than twenty states have no mandate to provide students with medically-accurate sexual education. As a result, students are left ill-equipped to protect themselves or others once they do decide to become sexually active.
The current outcry against comprehensive sexual education focuses on education as a gateway to promiscuity. The theory is, if you teach a student about sex, you will increase their interest in it. Furthermore, if you teach students how to prevent STIs or pregnancy, these concerns will no longer deter students from having sex, so they are more likely to do so – and with many partners.
The reality? Whether or not an adolescent’s school is teaching them about sex, they are most likely thinking about sex or already having sex. With or without education, adolescents and young adults will start having sex on their own timelines. It is a grave disservice, then, to deny adolescents the formal education to take care of themselves and their bodies as they enter sexual relationships.
In addition, according to the Guttamacher Policy Review, there is a “strong scientific consensus that providing people – in particular, adolescents – access to information and services related to sexual and reproductive health is not linked to increases in sexual activity.” However, despite “strong evidence debunking the ‘promiscuity’ argument, social conservatives continue to use it as a pretext to block or undermine policies and programs that make sexual and reproductive health information and services more available.”
This begs the question, if denying students sexual education does not decrease rates of STIs or unintended pregnancies, why is this the common practice for over 20 states? Do lawmakers want to stop adolescents and young adults from having sex for reasons other than disease and pregnancy prevention? Why? To prevent young people from having sex so they adhere to some anti-sex moral agenda?
Stigma and Shame
STIs, while extremely common, are perceived vastly differently than other diseases of the body. While everyone has the right to keep their health information private, someone may not be ashamed to admit they have COVID-19, but it would be hard to find someone who would freely admit to having chlamydia. This may not be surprising, but it should not be necessary.
According to a 2009 study**, the majority of adolescents believe that others hold negative views of people with STIs. In fact, the majority of respondents emphatically agreed that if they had an STD, 1) others would think they were unclean, 2) people would be disgusted by them, and 3) people would think they have bad morals. Not only is this an extremely heavy burden to bear for those who do contract STDs, but it prevents people from seeking STD testing for fear of the results.
A 2014 study*** of adolescents reported that STI-related stigma and shame was significantly associated with decreased odds of STI testing, decreased willingness to notify partners of STI status, and decreased willingness to deliver STI medication to a partner. Taken together, these factors contribute to greater spread of STIs and longer times between contraction and treatment. So while we know that early detection is absolutely critical, shame and stigma about STIs are significant obstacles to successful treatment.
Heteronormative sex is all around us – corporations regularly use sex appeal as a marketing strategy to sell products, TV and movies oversexualize women, and the internet is filled with pornography. While each of these realities comes with damaging consequences for people, our in-many-ways hypersexualized society still fails to incorporate sex in the most positive and constructive ways. Where is mandated, comprehensive sexual education? Where are open conversations about exploring sexuality in adolescence and adulthood? Where is the discussion about safer sex practices?
These conversations should not be confined to whispers behind closed doors or in doctors’ offices. If we want to see substantial positive change, not only fewer STIs, but also fewer unintended pregnancies, less shame around sex, and less sexual objectification and violence against women, we need to get real.
What You Can Do to Disempower STD/STIs:
- Get tested often and regularly and encourage your partner(s) to do the same. If you are sexually active, this means getting tested every 6 months. Visit FindSTDtest.org for testing centers near you.
- Use a barrier during vaginal, anal, and oral sex, or whenever you and your partner may share sexual fluids. The only time you can more safely forego a condom is if you are certain of your own and your partner’s current STD status.
- Pay attention to your own body. Notice what different parts feel typically like, so you can identify when things deviate from the norm. If a change concerns you, do not hesitate to call your doctor’s office.
- Feel free to discuss your sexual activity with your Primary Care Provider (PCP) or OB/GYN at every visit. If a provider does not bring up testing for STDs/STIs with you, speak up!
- If you want a particular STD test, make sure you get it. Oftentimes, patients will be discouraged from being tested for STIs for which they are deemed “low-risk.” If getting a certain test is going to give you peace of mind, get it!
- If learn that you have an STD, it does not have to be a big deal. It is your responsibility, however, to notify all relevant sexual partners. Oftentimes, health centers can help you notify these people or notify them for you. Check out these tips for talking with your partner about STDs.
- Reflect on your own judgement. How do you perceive others living with STIs? How might you improve on this?
- Destigmatize STIs and talk about sex. Share personal experiences with people you trust – they will be grateful you did.
Upcoming Article: December 3rd – Endometriosis