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Topics in Human Sexuality: Sexually Transmitted Diseases
Case Vignette
Marla is a 15-year-old high school sophomore. She has been sexually active since age 13 and has had multiple sexual partners. Although she tries to do the “responsible thing” by using protection, she has had unprotected sex at times, particularly when she has been drunk or high. Marla has recently been experiencing lower abdominal pain and foul smelling vaginal discharge and has noted that intercourse with her current boyfriend has been painful. She has her first gynecological examination and is dismayed to find that she has pelvic inflammatory disease (PID).

No discussion of human sexuality is complete without consideration of sexually transmitted diseases (STDs). Sexually transmitted diseases are infections that can be transferred from one person to another through sexual contact. According to the Centers for Disease Control and Prevention, there are over 15 million new cases of sexually transmitted diseases in the United States each year (CDC, 2008). There are more than 25 varieties of STDs. Although HIV remains the most well known STD with approximately 40 million people are currently living with HIV infection, other common STDs include chalymidia, gonorrhea, genital herpes and genital warts.

Adolescents and young adults are at great risk for contracting an STD because they are more likely to have multiple sexual partners (CDC, 2002). Of the new infections, almost half occur among people ages 15 to 24.

Many STDs can have serious consequence, both physical and emotional. For example, some STDs can lead to pelvic inflammatory disease, pelvic inflammatory disease, which can cause infertility. Other STDs, such as HIV, can be fatal. On an emotional level, people with illnesses such as genital herpes, which is incurable, often feel like outcasts and shun relationships due to shame around the disease.

It is important for mental health professionals working with people of all ages to be aware of STDs, their symptoms, treatments and the difficulties surrounding them.

Objectives:

After finishing this course, the participant will be able to:


  1. Discuss Chlamydia including symptoms, complications and treatment.

  2. Define Pelvic Inflammatory Disease (PID).

  3. Discuss gonorrhea, including symptoms, complications, pregnancy and treatment.

  4. Discuss syphilis, including stages, symptoms, complications, pregnancy and treatment.




  1. List the medical issues associated with HPV, as well as prevention and treatment of this virus.

  2. Describe the symptoms, psychological consequences and prevention of genital herpes.

  3. Discuss symptoms, diagnosis and treatment of pubic lice.

  4. Discuss HIV infection, including populations affected, transmission, symptoms and treatment

  5. Describe the signs, symptoms and treatment of trichomoniasis

  6. Discuss other genital infections

  7. Describe the incidence and reasons for STDs among adolescents

  8. List safe sex guidelines



Chlamydia
Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. In 2008, 1,210,523 Chlamydial infections were reported to the CDC. Chlamydia is caused by the bacterium, Chlamydia trachomatis. The disease is particularly dangerous for women and can cause serious complications that result in irreversible damage. Men with Chlamydia infection in the urethra are said to have nongonoccal urethritis or NGU (Webmd, 2010).

Symptoms

Chlamydia is known as a "silent" disease because the majority of infected people have no symptom. When they do occur, symptoms usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra. Women might have an abnormal vaginal discharge or a burning sensation when urinating. If the infection spreads from to the fallopian tubes, women may have lower abdominal pain, low back pain, nausea, fever, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.

Men are also generally asymptomatic (only 50% experience symptoms). Those who do have signs may have a discharge from their penis, a burning sensation when urinating or burning and itching around the opening of the penis.


Complications/PID
The complications of Chlamydia are of particular concern for women. Because the disease is often asymptomatic, women may not be treated for the disease. In about 10-15 % of women with untreated infection, Chlamydia spreads to the uterus or fallopian tubes, causing pelvic inflammatory disease (PID). PID is also common in gonorrhea. Each year about one million women develop PID. PID can cause infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain. Chlamydia may also increase the chances of becoming infected with HIV.

Treatment

Chlamydia is treated with antibiotics, most commonly Azithromycin or Doxycycline. Alternative antibiotic treatment is used for those with sensitivity to these drugs. It is important for partners to both be treated concurrently.


Gonorrhea
Gonorrhea (“the clap”) is the oldest STD on record. Symptoms of gonorrhea are described in the Old Testament. There has been a recent resurgence of this disease and the CDC estimates that more than 700,000 persons in the U.S. contract gonorrheal infections each year.
Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply in warm, moist areas of the reproductive tract, including the cervix, uterus, fallopian tubes and urethra. Gonorrhea can also grow in the mouth, throat, eyes, and anus.
Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Ejaculation need not occur for gonorrhea to be transmitted. The disease can also be spread from mother to baby during delivery.

Symptoms

People who are infected with gonorrhea may be asymptomatic. Most women are either asymptomatic or have mild symptoms. Symptoms can be mistaken for a urinary tract infection, and may include a painful or burning sensation when urinating, increased vaginal discharge, or bleeding between periods. Women with gonorrhea are at risk of developing complications from the infection, regardless of the severity of symptoms. Gonorrhea is a common cause of PID.

Men may also be asymptomatic. When symptoms do appear, they generally occur within five to eight days of infection but can take as long as 30 days. Symptoms include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Some men experience painful or swollen testicles. Gonorrhea can cause epididymitis, a painful condition of the ducts attached to the testicles causing infertility.

Symptoms of rectal infection include discharge, anal itching, soreness, bleeding, or painful bowel movements.



Additional Complications

Gonorrhea can spread to the blood or joints, causing a potentially life threatening condition. People infected with gonorrhea can also more easily contract HIV



Pregnancy

Women who have gonorrhea during pregnancy have higher rates of miscarriage, infection of the amniotic sac and fluid, preterm birth, and preterm premature rupture of membranes (PPROM).

Gonorrhea can be transmitted to the baby during delivery, and can cause serious complications including blindness. Most states require that all babies be treated with medicated eye drops soon after birth as a preventive measure.

Treatment

Gonorrhea is very treatable. Treatment generally involves either an injectible or oral antibiotic. A single dose is usually all that is required, but some antibiotics require longer courses. Ofloxacin, Cefixine, and Ceftriaxine are commonly prescribed.



Syphilis
Syphilis is a STD caused by the bacterium Treponema pallidum. It has been called "the great imitator" because so many of the signs and symptoms are indistinguishable from those of other diseases. Historically syphilis was also known as “the great pox.” It first appeared in Europe during the 1400s and became a pandemic by 1500.
According to the CDC, there were 36,000 reported cases of syphilis in 2006. Most occurred in people ages 20 to 39. Reported cases of congenital syphilis in newborns increased from 2005 to 2006, with 339 new cases reported in 2005 compared to 349 cases in 2006.
Although syphilis is less common than many of the other STDs, its affects are quite serious. It can cause sterility, and if left untreated result in damage to the nervous system and death.
Transmission
Syphilis is transmitted through direct contact with a syphilis sore. Sores can occur on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Syphilis can also be transmitted from pregnant women to their babies.
Symptoms
Many people infected with syphilis do not have any symptoms for years, which is quite problematic given the serious complications that can ensure from leaving the disease untreated. Although transmission occurs contact with a syphilis sore (carriers in the primary or secondary stage these sores may not be evident. Transmission may occur from persons who are unaware of their infection.

The stages are:



  • Primary Stage 
Marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is generally firm, round, small, and painless, lasts 3 to 6 weeks, and heals on its own. However, if the syphilis is not treated, the infection progresses to the secondary stage.

  • Secondary Stage 
This stage is characterized by skin rash and mucous membrane lesions. This stage typically starts with the development of a rash on one or more areas of the body. The rash generally consists of reddish brown spots both on the palms of the hands and the bottoms of the feet. Sometimes rashes associated with secondary syphilis are so faint they are barely noticeable. In addition an infected person may experience fever, swollen lymph glands, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.

  • Late and Latent Stages. The late stages of syphilis can develop in about 15% of people who have not been treated. They can appear as long as 10–20 years after the person was first infected. In the late stages of syphilis, the disease may damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. Signs and symptoms of this stage include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. The person may die in this stage of the illness.

Treatment
In its early stages syphilis is easy to cure. For a person who has had syphilis less than a year, treatment involves a single intramuscular injection of penicillin. Additional doses are needed to treat someone who has had syphilis for longer than a year. Penicillin (or another antibiotic for those who are allergic) will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

People who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed.


HPV (Human Papilloma Virus)
HPV stands for human papilloma virus, and is the most common sexually transmitted disease. Approximately 20 million Americans are currently infected with HPV. 50% of sexually active men and women get it at some point in their lives.
HPV is transmitted through genital contact, most often during vaginal and anal sex. HPV may also be passed on during oral sex and genital-to-genital contact.
Most people who contract HPV do not develop symptoms or health problems. But other, more aggressive strains of HPV can cause significant problems including:

  • Genital warts. Small warts in the genital area. Warts can appear within weeks or months after sexual contact with an infected partner, even if the partner has no signs of genital warts. Genital warts are not dangerous, but they can increase in number if left untreated.

  • Cervical cancer can be caused by untreated HPV. Women should receive regular screenings for cervical and other gynecological cancers.

  • Other HPV-related cancers include cancers of the vulva, vagina, penis, anus, and head and neck.

  • RRP. The HPV virus can cause warts to grow in the throat, a condition called recurrent respiratory papillomatosis or RRP. These warts can block airways, causing troubled breathing.

Prevention
Vaccines are effective protection against HPV. These vaccines are given in three shots, and are most effective prior to a person's first sexual contact.

  • Girls and women: Cervarix and Gardasil protect females against the types of HPV that cause most cervical cancers. Gardasil also protects against most genital warts. Both vaccines are recommended for 11 and 12 year-old girls, and for females 13 through 26 years of age, who were not previously vaccinated

  • Boys and men: Gardasil protects males against most genital warts. This vaccine is available for boys and men, 9 through 26 years of age.

Latex condoms also lower the risk of HPV infection.
Treatment
Generally people with HPV are treated for the symptoms of the disease, such as genital warts. Medications for warts include Podophyllin. Cryocautery can freeze warts. In harder to treat cases, laser therapy or surgical excision may be recommended.

Genital Herpes
Case Vignette
Jennifer is a 35-year-old woman who contracted genital herpes during college. She has struggled emotionally since contracting the illness and has generally avoided relationships, fearing that they could lead to sexual contact. The illness has caused severe emotional pain and distress.
Genital herpes is an STD caused by the herpes simplex viruses, most frequently type 2. Genital herpes infection is common in the United States. Herpes is passed through genital contact and can occur even when an infected partner does not have visible signs of the virus.
Nationwide, 16.2%, or about one out of six, people 14 to 49 years of age have genital HSV-2 infection. Over the past decade, the percentage of Americans with genital herpes has remained stable (CDC, 2010). Of all STDs, genital herpes is one of the most devastating as there is no cure. Outbreaks of the disease are unpredictable, and have significant consequences on a person’s sexual freedom, frequency and spontaneity.
Most individuals have no or only minimal signs HSV infection. Symptoms may appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender sores that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it generally is less severe.  Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over the years.

Complications

Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

Genital HSV can lead to potentially fatal infections in babies. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed.

Treatment

There is no known drug that will kill HSV. Acylovir can be used to prevent or reduce recurring symptoms.



Prevention
The most effective prevention for genital herpes is abstinence from sexual contact, or a mutually monogamous relationship with an uninfected partner.

Although latex condoms reduce the risk of genital herpes, genital ulcers in both male and female genital areas can occur in areas that are not covered by condoms.

Persons with herpes should abstain from sexual activity with uninfected partners when they have lesions or other symptoms. Even if a person does not have symptoms he or she can still infect sex partners. Sex partners can seek testing to determine if they are infected with HSV.
Pubic Lice
Pubic Lice (Phthirus pubis,) are also called crab lice or "crabs," are parasitic insects found primarily in the pubic or genital area of humans. These lice can also be found in armpit hair and eyebrows. The primary age group infected by pubic lice are teenagers. Lice infestation is usually spread during sexual activity. Less commonly can be spread through contact with objects such as toilet seats, sheets, blankets, or bathing suits.

Risk factors for public include having multiple sexual partners, sexual contact with an infected person and sharing bedding or clothing with an infected person.



Symptoms

The most common symptom of pubic lice is itching in the pubic area. The itching often intensifies at night). This itching may start soon after being infected with lice, or it may not start for up to 2 to 4 weeks after contact. Other symptoms include skin reaction that is bluish-gray in color, and in the genital area due to bites and/or scratching. Scratching the skin in this area could also result in irritation leading to a secondary infection.



Treatment

Public lice are very treatable using a prescription wash containing permethrin. Two of these washes are Elimite and Kwell. Following the wash, the person must comb the pubic hair with a fine-toothed comb to remove nits. Generally a single treatment is all that is necessary. In addition to this treatment, all clothing and linens should be thoroughly washed in hot water.



Human Immunodeficiency Virus (HIV)
HIV or Human Immunodeficiency Virus is the retrovirus responsible for AIDS. While initially HIV was thought to be a disease that was limited to the homosexual population and IV drug users, this impression has changed in the past ten years. Approximately one-third of new HIV diagnoses are among heterosexuals. Male-to-male sexual contact accounts for approximately half of new diagnoses and intravenous drug use contributes to the remaining cases. The biggest change in the HIV picture is women, who are increasingly contracting the virus. In the United States, approximately 25% of new diagnoses are in women, and this proportion continues to rise (World Health Organization, 2007).
Among younger people, minorities and teen girls have been hard hit by HIV/AIDS. Younger African Americans represented 65% of AIDS cases reported among 13-19 year olds in 2002; Latino teens represented 20%. In 2002, girls represented 51% of HIV cases reported among 13-19 year olds, compared to 30% of cases reported among people over age 25 that same year (Kaiser Family Foundation and Seventeen, 2003).
Transmission

There are a number of possible routes of transmission for HIV.


1. Most commonly, HIV is spread by having sex with an infected partner. The virus enters the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex. Unprotected anal intercourse carries a higher risk than most other forms of sexual activity.
2. HIV can be spread among injection-drug users who share needles or syringes that are contaminated with blood from an infected person.
3. Women can transmit HIV to their babies during pregnancy or birth. For women who are pregnant and HIV positive, doctors generally recommended anti-HIV medications to prevent babies from becoming infected.
4. HIV can spread through accidental needle sticks or contact with infected fluids. It is rare nowadays that HIV would be spread from contaminated blood products.
HIV cannot be spread by casual contact. HIV is not an airborne, water-borne or food-borne virus, and does not survive for very long outside the human body. Ordinary social contact such as kissing, shaking hands, coughing or sharing silverware does not result in the virus being passed from person to person.
Symptoms

There are typically a number of phases of HIV symptoms. There is a symptom-free period, a period of early infection. The disease may then progress to AIDs (acquired immune deficiency disorder).

Many people with HIV do not know they are infected. Symptoms may not occur immediately. Some people who are exposed to HIV do not show any signs of the illness for up to 10 years. In other cases people have flu-like symptoms within days of exposure, but these symptoms remit quickly. During this asymptomatic phase, the virus continues to multiply and infects and kills the cells of the immune system. The HIV virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells. Although there are no symptoms associated with this stage of the disease, it is still contagious and can be passed along to others.
The later stage of the disease is AIDS. In this stage the body loses its ability to fight infections. People who have AIDS may contract a number of serious and potentially illnesses. These illnesses are known as opportunistic infections because they occur as a result of the weakened immune system. Opportunistic infections associated with AIDS include:
• Pneumonia

• Toxoplasmosis

• Yeast infections of the esophagus
The weakened immune state of AIDs can also lead to cancers. These cancers are difficult to treat and may be fatal.
• lymphoma in the brain

• Kaposi’s sarcoma. This cancer was rare prior to AIDs and its incidence helped the CDC first identify AIDs as a medical condition.


Treatment
Treatment of HIV has progressed considerably since it was first recognized in the 1980s primarily due to newer antiretroviral therapies. HAART (highly active antiretroviral therapy) is a potent drug cocktail used to suppress the growth of HIV, the retrovirus responsible for AIDS. A combination of at least three drugs is the recommendation to keep the virus from replicating. The following medications are widely used in treatment (EMedicine Health, 2010):
The following are the different classes of medications used in treatment.

Reverse transcriptase inhibitors (AZT/Retrovir): Inhibit the ability of the virus to make copies of itself and to keep the virus from multiplying.


Protease inhibitors (PIs): Interrupt virus replication at a later step in its life cycle, preventing cells from producing new viruses. When used in a cocktail they also reduce the chances that the virus will become resistant to medications.
Fusion and entry inhibitors: Newer agents that keep HIV from entering human cells.
Integrase inhibitors stop HIV genes from becoming incorporated DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.
These medications are helpful in allowing a person who is infected with HIV to live longer and be less symptomatic. They do not cure HIV or AIDS.

Trichomoniasis
Trichomoniasis is a sexually transmitted disease that affects both women and men, although symptoms are more common in women. It is the most common curable STD in young, sexually active women. There are an estimated 7.4 million new cases each year.
Trichomoniasis is caused by the parasite, Trichomonas vaginalis. The vagina is the most common site of infection in women, and the urethra is the most common site of infection in men.
Symptoms
Most men with trichomoniasis do not have symptoms, but some may experience a mild irritation inside the penis, discharge, or burning after urination or ejaculation. Signs of the infection in women include a frothy, yellow-green vaginal discharge with a strong odor. The infection may cause discomfort during intercourse and urination, and irritation and itching of the vagina. Symptoms usually appear within 5 to 28 days of exposure.
Other Genital Infections
Vaginitis. Vaginitis is not considered an STD because it is not transmitted by sexual contact. Vaginitis is an inflammation of the vagina that can result in discharge, itching and pain. It is common among women, particularly those of college age. Vaginitis is generally caused by a change in the normal balance of vaginal bacteria or an infection. Vaginitis can also result from reduced estrogen levels after menopause.

The most common types of vaginitis are:

Bacterial vaginosis, which results from overgrowth of one of several organisms normally present in the vagina. Women with bacterial vaginosis are also at a greater risk of contracting HIV and other sexually transmitted infections.

Monilia or yeast infections, which are usually caused by a naturally occurring fungus called Candida albicans.

Vaginal atrophy (atrophic vaginitis), which results from reduced estrogen levels after menopause

Vaginitis symptoms may include a change in color, odor or amount of vaginal discharge, itching or irritation, pain during intercourse or urination or spotting. Treatment options depend on the type of vaginitis and may include prescription and OTC suppositories.



Adolescents and STDs
Most STDs are found in all age groups, with the exception of pubic lice, which is found primarily in adolescents. Compared to older adults, adolescents (10- to 19-year-olds) are at higher risk for acquiring STDs for a number of reasons, including limited access to preventive and regular health care and physiologically increased susceptibility to infection. Approximately one in four sexually active teens contracts an STD every year. An estimated half of all new HIV infections occur in people under

age 25.
Given these statistics, education and prevention efforts are key.


Safe Sex Guidelines
With all STDs, and particularly HIV, the most effective counsel is safe sex or abstinence. Hyde and DeLamater (2003) provide the following safe sex guidelines:


  1. For those who choose to be sexually active, have sex only with one consistent stable sexual partner.

  2. For those who are active with multiple partners, use a latex condom, which is the most effective protection against HIV.

  3. If there is risk that a partner is infected, abstain from sex or use alternative forms of sexual expression that do not involve genital contact.

  4. Abstain from being sexually active with people who have had multiple sexual partners.

  5. Do not engage in anal sex if there is any chance that a partner has an STD.

  6. If there is any chance of having been exposed to an STD, have a blood test to verify.

References

Centers for Disease Control. Chlamydia Fact Sheet. Downloaded July 27, 2010 from http://www.cdc.gov/std/chlamydia/stdfact-chlamydia.htm



Centers for Disease Control. Genital Herpes Fact Sheet. Downloaded July 29, 2010 from http://www.cdc.gov/std/herpes/stdfact-herpes.htm
Centers for Disease Control (2008). Sexually transmitted diseases surveillance. Downloaded July 20, 2010 from http://www.cdc.gov/std/stats08/main.htm
Centers for Disease Control (2002). Sexually transmitted diseases in adolescents and young adults. Downloaded July 20, 2010 from http://www.cdc.gov/std/stats02/adol.htm
Ehow.com. HIV symptoms in phases. Accessed July 28, 2010 from http://www.ehow.com/about_5382489_hiv-symptoms-phases.html
Emedicine Health. HIV/AIDS. Accessed July 28, 2010 from http://www.emedicinehealth.com/hivaids/article_em.htm
Holmes, K., Sparling, P., Stamm, W., Piott, P., Wasserheit, J., Corey, L. & Cohen, M. (2008). Sexuallu transmitted diseases. New York: McGraw Hill.
Hyde, J.S. & DeLamater, J.D. (2003). Understanding human sexuality. New York: McGraw Hill.
Kaiser Family Foundation and Seventeen (2003). SexSmarts: Virginity and thefFirst time.
ebmd. Sexual conditions guide. Accessed July 29, 2010 from http://www.webmd.com/sexual-conditions/guide/
World Health Organization (2007). Global HIV prevalence has leveled off. Accessed July 28, 2010 from http://www.who.int/mediacentre/news/releases/2007/pr61/en/index.html


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