STDs are behavior-linked diseases that result from unprotected sex. Behavioral, biological, and social factors contribute to the likelihood of contracting an STD. Wasserheit (1994) has described how microenvironments, including microbiological, hormonal, and immunologic factors, influence individual susceptibility and transmission potential for STDs. These microenvironments are partially determined by an individual's sexual practices, substance use, and other health behaviors. These health behaviors, in turn, are influenced by socioeconomic, epidemiologic, and other macroenvironmental factors. In this chapter, the committee examines biological factors contributing to the spread of STDs and shows how both broad and specific social factors affect exposure to STDs and create obstacles to STD prevention. In Chapter 4, the committee examines behavioral factors contributing to risk of STDs.
In Chapter 2, several biological factors that affect the risk of acquiring or
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--> 3 Factors that Contribute to the Hidden Epidemic Highlights One-quarter of adolescents and young adults in high-risk age groups for STDs do not have health care coverage. Only 11 percent of teenagers surveyed reported getting most of their information regarding STDs from their parents or other family members. Among prime-time network television shows, there is only 1 portrayal of protective behavior or comment regarding STDs for every 25 instances of sexual behavior shown. Nearly 70 percent of students in the twelfth grade have had sexual intercourse and 27 percent of twelfth-grade students have had sex with four or more partners. Knowledge and awareness of STDs among the public is poor; almost two-thirds of women 18-60 years of age surveyed knew nothing or very little about STDs other than AIDS. STDs are behavior-linked diseases that result from unprotected sex. Behavioral, biological, and social factors contribute to the likelihood of contracting an STD. Wasserheit (1994) has described how microenvironments, including microbiological, hormonal, and immunologic factors, influence individual susceptibility and transmission potential for STDs. These microenvironments are partially determined by an individual's sexual practices, substance use, and other health behaviors. These health behaviors, in turn, are influenced by socioeconomic, epidemiologic, and other macroenvironmental factors. In this chapter, the committee examines biological factors contributing to the spread of STDs and shows how both broad and specific social factors affect exposure to STDs and create obstacles to STD prevention. In Chapter 4, the committee examines behavioral factors contributing to risk of STDs. Biological Factors In Chapter 2, several biological factors that affect the risk of acquiring or
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--> transmitting STDs, such as gender and other preexisting or concurrent STDs including HIV infection, were discussed. Other biological factors that contribute to the spread of STDs include the lack of conspicuous signs and symptoms manifested by infected persons, the long lag time from initial infection to signs of severe complications, and the propensity of STDs to more easily infect young women and female adolescents than men. In addition, the committee summarizes the potential impact of male circumcision, vaginal douching, risky sexual practices, and other factors on the spread of STDs or risk of sequelae. Asymptomatic Infections As discussed in Chapter 2, many STDs either do not produce acute symptoms or clinical signs of disease or do not produce symptoms sufficiently severe for an infected individual to seek medical attention. For example, as many as 85 percent of women with chlamydial infection are asymptomatic (Fish et al., 1989; Judson, 1990; Stamm et al., 1990). A study of college women seen for routine gynecological examinations found that 79 percent of those who tested positive for chlamydial had no symptoms of disease (Keim et al., 1992). Asymptomatic infection also contributes to the spread of viral STDs including HIV infection, hepatitis B virus infection, genital herpes, and human papillomavirus infection. HIV infection is a prime example of how certain STDs that may go unrecognized for many years allow wide dissemination of infection before it is detected and treated. Lack of awareness that most cases of certain STDs are asymptomatic or otherwise unrecognized leads many susceptible persons to falsely believe that it is possible to tell whether a potential partner is infected with an STD, and similarly explains why many infected asymptomatic persons fail to take precautions to avoid transmitting their infection. Even when symptoms are present, many STDs have nonspecific signs and symptoms, making them difficult to diagnose without laboratory tests. Asymptomatic infection, therefore, is an extremely important biological factor that reduces the likelihood that infected individuals will seek health care and/or receive appropriate diagnoses. This hinders detection and treatment of the infection, increases the period of infectiousness, and thereby promotes the spread of the infection. Lag Time to Complications Another biological factor that contributes to the STD epidemic is the long period of time (sometimes years or decades) from initial infection until the appearance of clinically significant problems. The best examples of sexually transmitted pathogens and complications that have long lag times are (a) human papillomavirus and cervical cancer and (b) hepatitis B virus and liver cancer. In both instances, the initial phase of the infection is often asymptomatic and creates obstacles to detection and treatment, as noted above. In addition, the clinical
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--> signs of the associated life-threatening cancers usually do not appear until years or decades after the initial infection. Because of this phenomenon, many cases of STD-related cancers and other long-term complications are not attributed to a sexually transmitted infection. At both individual and population levels, the lack of a perceived connection between sexually transmitted infections and these serious complications reduces both the perceived significance of STDs and the motivation to undertake preventive action. Although the lag time between exposure to HIV and development of clinical symptoms of AIDS likewise can be quite long, there is greater awareness of the link between unprotected sex and the risk of acquiring HIV, and ultimately AIDS, compared to other STDs. Increased Susceptibility of Women and Female Adolescents Age and gender may influence risk for an STD. Specifically, as mentioned in Chapter 2, young women and female adolescents are more susceptible to STDs compared to their male counterparts because of the biological characteristics of their anatomy (Cates, 1990). This is because in puberty and young adulthood, specific cells (columnar epithelium) that are especially sensitive to invasion by certain sexually transmitted organisms, such as chlamydial and gonococcus, extend from the inner cervix out over the vaginal surface of the cervix, where they are unprotected by cervical mucus. These cells eventually recede into the inner cervix with age. In addition to biological factors, women and female adolescents may also find it more difficult than men to implement protective behaviors, partly because of the power imbalance between men and women (Elias and Heise, 1994; IOM, 1994). For example, condoms are the most effective protection against STDs for sexually active persons, but the decision whether to use a condom is ultimately up to the male partner, and negotiating condom use may be difficult for women (Rosenberg and Gollub, 1992). The determinants of condom use are discussed in Chapter 4. Other Biological Factors Other biological factors that may increase risk for acquiring, transmitting, or developing complications of certain STDs include presence of male penile foreskin, vaginal douching, risky sexual practices, use of hormonal contraceptives or intrauterine contraceptive devices, cervical ectopy, immunity resulting from prior sexually transmitted or related infections, and nonspecific immunity conferred by normal vaginal flora. Lack of male circumcision seems to increase the risk of acquiring and perhaps transmitting certain STDs. A review of 30 published epidemiological studies that examined the relationship between HIV infection and male circumcision concluded that most studies found a statistically significant association between
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--> lack of circumcision and increased risk for HIV infection (Moses et al., 1994). In a prospective study of men at high risk for STDs, those who were not circumcised were 8 times as likely to become infected with HIV than circumcised men (Cameron et al., 1989). Another study of gay men suggested that uncircumcised men were twice as likely to be infected with HIV compared to circumcised men (Kreiss and Hopkins, 1993). As a result of these studies, some have proposed that male circumcision be considered an intervention to prevent HIV infection. Several studies have found associations between lack of circumcision and other STDs, including chancroid (Aral and Holmes, 1990). It has been hypothesized that lack of circumcision increases risk for STDs because (a) the cells that line the fold of skin that is removed by circumcision are prone to trauma or infection, (b) this fold of skin may serve as a reservoir for pathogens, and (c) this fold of skin may increase the likelihood that infections will go undetected (Aral and Holmes, 1990). Vaginal douching seems to increase risk for pelvic inflammatory disease (Forrest et al., 1989; Wolner-Hanssen, Eschenbach DA, Paavonen J, Stevens CE, et al., 1990;). In one study, compared to women who did not douche, women who douched during the previous 3-month period were twice as likely to have clinical pelvic inflammatory disease (Scholes et al., 1993). The risk for pelvic inflammatory disease seems to increase with greater frequency of douching (Wolner-Hanssen, Eschenbach DA, Paavonen J, Stevens CE, et al., 1990; Scholes et al., 1993). Certain sexual practices such as receptive rectal intercourse predispose to STDs. As mentioned in Chapter 2, STDs such as HIV infection and hepatitis B virus infection are more easily acquired by rectal intercourse than by vaginal intercourse. This may be because the bleeding and tissue trauma that can result from rectal intercourse facilitate invasion by pathogens. Other sexual practices, such as sex during menses and "dry sex," also predispose to acquisition of an STD. The influence of hormonal contraceptives on acquisition and transmission of STDs is not fully defined. However, several studies have found oral contraceptive use to be associated with increased risk of acquiring chlamydial infection (Critchlow et al., 1995) but with decreased risk of developing pelvic inflammatory disease among women with chlamydial infection (Wolner-Hanssen P, Eschenbach DA, Paavonen J, Kiviat N, et al., 1990; Kimani et al., 1996). Some, but not all, studies have found an association of oral contraceptives with increased risk of HIV acquisition (Cates, in press). A recent study in Kenya has demonstrated that use of oral contraceptives or injectable progesterone among women with HIV-1 infection is associated with increased shedding of HIV-1 DNA from the cervix (Mostad et al., 1996). In one animal model study, monkeys with progesterone implants were several times more likely to become infected with the simian immunodeficiency virus than monkeys who did not have such implants (Marx et al., 1996). More study is indicated, but these data raise the
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--> possibility that hormonal contraceptives may increase the likelihood of infectious genital tract secretions in HIV-infected women and/or increase susceptibility to HIV infection. Cervical ectopy (extension of columnar epithelial cells present in the adult endocervix onto the exposed portion of the cervix within the vagina) has also been found to be a risk factor for HIV infection (Moss et al., 1991). Among women attending an STD clinic and among college women, cervical ectopy was positively associated with use of oral contraceptives and with chlamydial infection; ectopy disappeared with increasing age (Critchlow et al., 1995). As previously discussed, other STDs can increase risk for acquiring or transmitting HIV infection. However, prior infection with certain STDs can provide specific immunity against reinfection with the same pathogen (Plummer et al., 1989; Brunham et al., 1994). Cross-immunity (protection conferred by prior infection with a different pathogen) also occurs. For example, a prospective study of women found that asymptomatic shedding of herpes simplex virus type 2 occurs more often during the first three months after acquisition of primary type 2 disease (Koelle et al., 1992). Among persons with herpes simplex virus type 2 infections, previous infection with type 1 virus was associated with a lower rate of asymptomatic viral shedding. This observation suggests that, as prevalence of herpes simplex virus type 1 infections in childhood decline, the risk of herpes simplex virus type 2 infection may be increased when this STD is encountered by a sexually active adult. Nonspecific immunity may make some individuals more resistant to certain STDs even though they have never experienced prior STDs or related infections. For example, the normal vaginal flora contains hydrogen-peroxidase-producing bacteria that have antimicrobial activity. Recent data suggest that women with bacterial vaginosis who lack hydrogen-peroxidase-producting bacteria (lactobacilli) are at increased risk of gonorrhea (Sharon Hillier and King Holmes, University of Washington, unpublished data, 1996; Martin et al., 1996). Social Factors On a population level, preventing the spread of STDs is difficult without addressing social issues that have a tremendous influence on transmission of STDs. Some fundamental societal problems such as poverty, lack of education, and social inequity indirectly increase the prevalence of STDs in certain populations. In addition, lack of openness and mixed messages regarding sexuality create obstacles to STD prevention for the entire population and contribute to the hidden nature of the STDs. In the following discussion, the committee highlights several social problems that directly affect the spread of STDs in subpopulations and shows how societal norms regarding sexuality impede prevention of STDs. In Chapter 4 the committee describes interventions that can be used to lessen the
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--> adverse impact of these social problems on STDs, even if these dilemmas are not solved directly. Poverty and Inadequate Access to Health Care Health insurance coverage enables individuals to obtain professional assistance in order to prevent potential exposures to sexually transmitted infections and to seek care for suspected STDs. Uninsured persons delay seeking care for health problems longer than those who have private insurance or Medicaid coverage (Freeman et al., 1987; Donelan et al., 1996). Those with private health insurance who are living at or near poverty level have limited access to health care because of copayments and deductibles that are typically part of private insurance coverage (Freeman and Corey, 1993). Medicaid coverage is often less effective than private health insurance coverage since many physicians refuse to treat Medicaid beneficiaries, thereby restricting access to comprehensive health services (Schwartz et al., 1991). Private health insurance generally provides the most comprehensive coverage with the greatest access to physicians and other health care professionals. However, not all plans offer adequate coverage for STD-related services. Little information is available on coverage for STD-related services in the private health care sector. A recent study of how women pay for reproductive health care suggests that many health plans either do not cover some important STD-related preventive reproductive health services or require copayments and deductibles for these services (WREI, 1994). STD-related diagnostic and treatment services are covered under general clinical care. However, the study found that only about half of all health plans cover preventive care such as routine gynecological examinations that may be important in detection of asymptomatic sexually transmitted infections. Managed care organizations may provide better coverage for certain STD-related services than do many indemnity health plans, but they pose different challenges to the prevention of STDs, particularly for many Medicaid beneficiaries enrolled in managed care. Most managed care organizations require their enrollees to obtain all their health services from the plan's network of providers. This disrupts established patterns of STD care for many women on Medicaid by denying patients access to their preferred providers. A recent study found that neither the federal government nor the states had taken steps to ensure that Medicaid beneficiaries enrolled in managed care organizations could obtain services from family planning programs or public STD clinics (Rosenbaum et al., 1995). A number of family planning programs have taken the initiative to develop contracts with managed care organizations that serve Medicaid clients, thus both avoiding the problem of nonreimbursed out-of-plan use and retaining an important source of revenue for their program (Orbovich, 1995). This is an especially important policy issue as states increasingly encourage or require Medicaid
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--> beneficiaries to enroll in managed care organizations. The role of managed care organizations and other health plans in STD prevention is further discussed in Chapter 5. Health insurance coverage influences where people obtain STD services. A recent study found that uninsured women and those covered by Medicaid were far more likely to obtain reproductive health services from a public or community-based clinic rather than a private physician's office, compared to women who were covered by either a managed care organization or other private health insurance (Sonenstein et al., 1995). Even those with adequate insurance coverage may be reluctant to obtain care for potential STDs from their regular health care providers because of the social stigma associated with these infections. A significant number of persons with private insurance are reluctant to bring STD exposures to the attention of their family doctor or health plan and prefer the anonymity of a public STD clinic or other public clinic (Celum et al., 1995). In 1993, 40.9 million Americans, or 18.1 percent of the nonelderly population, were not covered by any public or private health insurance coverage, up from 39.8 million or 17.8 percent of the nonelderly population in 1992 (EBRI, 1995b). Further analysis of these data revealed that of the 1.1 million increase in uninsured persons from 1992 to 1993, 900,000 or 81.8 percent of the newly uninsured population were children and youth under 18 years of age (EBRI, 1995a). The age and ethnic groups with the highest rates of STDs are also the groups with the poorest access to health services. One-third of persons in high-risk age groups are uninsured or covered by Medicaid (UCLA Center for Health Policy Research, unpublished data, 1996). Among persons 15-29 years of age, 25 percent are completely uninsured (Figure 3-1), including one in every five persons 15-20 years old and at least one in every four persons 21-29 years old. One in every nine persons 15-29 years old depends on Medicaid or other publicly sponsored insurance for health care access. In addition, Hispanic and African Americans are most likely to lack insurance coverage. Poverty and other socioeconomic factors also contribute to STD risk in other ways. Even if a person in poverty perceives himself or herself to be at risk for an STD, he or she may not practice preventive behaviors if there are other risks that appear more imminent or more threatening or both (Mays and Cochran, 1988; Ramos et al., 1995). Mays and Cochran (1988:951) point out that poor women of certain ethnic groups face continual danger and have few resources to deal with them: "Competition for these women's attention includes more immediate survival needs, such as obtaining shelter for the night, securing personal safety or safety of their children, or interfacing with the governmental system in order to obtain financial resources." Traditional cultural values associated with passivity and subordination also diminish the ability of many women to adequately protect themselves (Amaro, 1988; Stuntzner-Gibson, 1991).
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--> Figure 3-1 Distribution of 15-29-year-old persons in the United States by health insurance coverage, 1993. SOURCE: UCLA Center for Health Policy Research, unpublished data, 1996. Substance Use Substance use, especially drugs and alcohol, is associated with STDs at both population and individual levels.1 At the population level, rates of STDs are high in geographic areas where rates of substance use are also high, and rates of substance use and STDs have also been shown to co-vary temporally (Greenberg et al., 1991). At the individual level, persons who use substances are more likely to acquire STDs (Marx et al., 1991; Anderson and Dahlberg, 1992; Shafer et al., 1993). There are several possible reasons for this association. One is that underlying social and individual factors lead both to higher rates of STDs and to greater use of substances. Social factors such as poverty, lack of economic and educational opportunities, and weak community infrastructure may contribute to both outcomes. Individual factors, such as risk-taking and low self-efficacy, could similarly contribute to both outcomes. 1 Much of the following discussion of substance use and STDs was based on the following paper: Beltrami JF, Wright-DeAgüero LK, Fullilove MT, St. Louis ME, Edlin BR. Substance abuse and the spread of sexually transmitted diseases. Commissioned paper for the IOM Committee on Prevention and Control of STDs.
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--> Use of substances may also directly contribute to risk of STD infection by undermining an individual's cognitive and social skills, thus making it more difficult to take actions needed to protect themselves against STDs. For example, at low doses cocaine can decrease inhibitions and heighten sexuality, leading to increased numbers of sexual encounters and partners and to increased high-risk sexual behaviors (Marx et al., 1991). In addition, drug users may be at greater risk for STDs as a result of the practice of trading sex for drugs; in these situations, drug users have a large number of high-risk partners (Marx et al., 1991). Those who are involved in frequent and sustained use of substances are most likely to be at risk for STDs. Data from the National Household Survey on Drug Abuse indicate that, in 1994, approximately 54 percent of the U.S. population age 12 and over and 63 percent of those age 18-25 used alcohol in the prior month (SAMHSA, 1995). In addition, approximately 6 percent of the U.S. population used an illicit drug in the prior month, and there were approximately 500,000 crack cocaine users during the year. To illustrate the broad impact of substance use on STD transmission, the committee focused on the association of STDs with use of two substances: crack cocaine, often used by disenfranchised groups, and alcohol, which is commonly used by most Americans, especially adolescents. In the following sections, the committee describes the evidence for the association between substance use/abuse and STDs. Impact of Crack Cocaine on STD Transmission Numerous studies show that drug use is associated with increased risk of STDs, including HIV infection. Marx and colleagues (1991) reviewed 16 epidemiologic studies that examined drug use, sexual behavior, and STDs. Crack use paralleled the trends for syphilis, gonorrhea, chancroid, and HIV infection, both temporally and among the groups most affected. For example, a study at an STD clinic in 1990 in Trenton, New Jersey, evaluated the relationship between syphilis and behavior related to sexual activity and drug use (Finelli et al., 1993). The study showed that in addition to crack use and lack of condom use within the past three months, a high number of sex partners, drug-using partners, and partners exchanging sex for drugs increased the risk for syphilis, especially for women. The association of syphilis and crack cocaine may lead to concentrations of the disease in specific social networks and in crack houses. For example, in 1991 and 1992, a series of syphilis outbreaks in four rural towns in Texas were linked to crack users exchanging sex for drugs (Schulte et al., 1994). Three outbreaks were concentrated in neighborhoods where crack cocaine dealers worked and where exchange of sex for drugs or money was common. All 26 cases in one outbreak were linked to a single sex worker. In a second outbreak, all 34 cases were among people frequenting a crack house, 3 of whom were sex workers. In
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--> the third and fourth outbreaks, 12 percent and 50 percent of infected persons, respectively, reported exchanging sex for drugs or money. Crack cocaine use is associated with high-risk sexual behaviors such as multiple partners and unprotected sex. McCoy and Inciardi (1993) found that in a sample of women who did not inject drugs, crack was found to be the strongest predictor of high-risk sexual behavior. Edlin and others (1994) reported in a multisite study that crack smokers were at greater risk for HIV infection compared to persons who did not smoke crack. In addition, male crack users are more likely than those who do not use crack to choose high-risk partners (Seidman et al., 1994). Compared with heroin users, men who used crack also are more likely to have a greater number of sex partners and to receive money or drugs for sex (Hudgins et al., 1995). How Drug Use Increases STD Transmission How does substance use increase STD transmission on a population level? Examining the population-wide impact of crack cocaine may provide answers. Crack cocaine appears to play a central role in the transmission of STDs within various social networks. The transmission and persistence of STDs in a population or social network are dependent on the rate of partner change, the probability of transmission of infection from an infected individual to a susceptible individual, and the duration of infectiousness (May and Anderson, 1987). The rate of partner change can be considered to be a function of a complex set of interactions involving social and sexual networks, sex partner mixing patterns, and other parameters. The rate of partner change is influenced by the exchange of sex for drugs that results from crack cocaine use (Marx et al., 1991; Edlin et al., 1994). The probability of infection per sexual encounter is influenced both by the type of sexual contact and by specific sexual practices and is strongly affected by the use of condoms. The urgency to use crack may overwhelm any consideration of condom use. Because crack use in persons with STDs discourages health-care-seeking behavior (Webber et al., 1993) and modifies social norms with respect to behavior such as engaging in unprotected sex (Finelli et al., 1993) or having multiple sex partners (Greenberg et al., 1992), the duration of infectiousness in these persons may be lengthened. In addition, explosive bursts of new partner acquisition, particularly in crack houses or other settings where addicted persons trade sex for drugs, represent a potentially powerful mechanism for amplifying and maintaining chains of transmission of genital ulcer diseases among crack users. Crack also appears to influence health-care-seeking behavior among pregnant women infected with STDs, resulting in late or absent prenatal care (Warner et al., 1995); frequent changes in prenatal care providers may complicate appropriate follow-up for positive serologic tests.
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--> Association Between Alcohol Use and STDs Although some studies have failed to find a correlation between alcohol use and unprotected heterosexual intercourse (Leigh and Stall, 1993; Leigh et al., 1994), most studies show that both average and extreme alcohol use are associated with greater risk of STDs. From 1988 to 1990, 2,896 adults completed the General Social Survey, a nationally representative household survey of U.S. adults (Anderson and Dahlberg, 1992). Respondents who reported that they sometimes drink ''more than they should" were more likely to have had the following three outcome variables compared to those who did not: sexual intercourse with two or more partners, intercourse with five or more partners, and intercourse with a stranger in the past year. A household survey in the San Francisco Bay area showed that having ever had an STD was associated with nonmonogamous behavior; with having more than five sex partners in the last five years; and, at a minimum with, three kinds of drinking behavior: going to a bar at least monthly, getting drunk at least annually, and having five or more drinks at one sitting in the last year (Ericksen and Trocki, 1992). In addition, a large nationwide survey in 1991 and 1992 showed that persons who occasionally drank five or more drinks at one sitting were significantly more likely to have multiple partners, be nonmonogamous, and participate in other high-risk sexual activities (Caetano and Hines, 1995). A number of studies have reported that for men who have sex with men, drug and alcohol use are risk factors for relapse into unsafe sexual behaviors (Stall et al., 1986; Siegel et al., 1989). Alcohol use among adolescents has also been found to be associated with high-risk sexual behaviors (Hingson et al., 1990; Shafer et al., 1993; Lowry et al., 1994). In addition, alcohol use has been found to be a risk factor for HIV-related sexual behaviors among runaway youth (Koopman et al., 1994), the mentally ill (Kalichman et al., 1994), and seronegative female partners of HIV-seropositive men (Kennedy et al., 1993). In a survey of attendees at an STD clinic, drug and alcohol use was found to correlate with unprotected sex during their most recent sexual intercourse (CDC, 1990). In a multiple logistic regression analysis controlling for age, race, income, number of sex partners, and other variables, failure to use condoms was significantly associated with drug and alcohol use at the last sexual encounter for heterosexual men. Sexual Abuse and Violence Sexual violence against women and sexual abuse of children are societal problems of enormous consequences. Approximately 500,000 women were raped annually in 1992 and 1993 in the United States (U.S. Department of Justice, 1994), and studies suggest that approximately one in three young girls and one in six young boys may experience at least one sexually abusive episode by the time they reach adulthood (Guidry, 1995). Women who have been sexually abused
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--> people. Although few adolescents could name an STD other than HIV/AIDS, they were more likely than adults to answer correctly that some STDs (in addition to HIV/AIDS) are incurable and that some STDs are asymptomatic. STDs are far more common than is generally perceived by the general population or health care professionals. For example, while there is widespread awareness of genital herpes infections, there also are many misperceptions about them. Perhaps the single largest misperception concerns the prevalence of herpes infection. In a recent national survey of sexual behavior (Laumann, Gagnon, et al., 1994), 2 percent of survey respondents age 18-59 reported having had genital herpes. In contrast, population-based studies suggest that the prevalence of antibodies to herpes simplex virus type 2, which causes about 85 percent of initial episodes of genital herpes, was 21.7 percent in 1990 (Johnson et al., 1993). The reason for the substantial differences between the low prevalence of self-reported genital herpes infections and the far higher true prevalence of the disease may be misperceptions regarding the clinical manifestations of genital herpes infections. Herpes is most often described as an episodic illness, typically presenting as a painful genital eruption and recurring with similarly painful lesions of shorter duration. In fact, a quite different clinical spectrum of infection exists. Herpes infection may manifest as mild initial episodes and asymptomatic shedding of the virus (Koutsky et al., 1992). Other studies indicate that most genital herpes infections are spread by asymptomatic individuals who often are unaware of their infections (Mertz et al., 1992). Conclusions Biological and social factors contribute to the hidden nature of the STD epidemic. Biological factors, including the lack of signs and symptoms in infected persons, the long lag time from initial infection until signs of severe complications, and the propensity for STDs to more easily infect women than men, contribute to the general lack of awareness of STDs among health professionals and the public. A number of social factors contribute to the risk of STDs and place a disproportionate burden on certain populations in the United States. Poverty and inadequate access to health care, substance use, and sexual abuse all increase an individual's risk for STDs. Lack of health insurance is particularly acute among the age and ethnic groups at greatest risk of STDs. Even for the insured, access to comprehensive STD-related services may be difficult. Sex workers, persons in detention facilities, the homeless, migrant workers, and other disenfranchised persons represent "core" transmitters of STDs in the population. Efforts to prevent STDs in the entire community are not likely to be successful unless these groups receive appropriate STD-related services. Many Americans are reluctant or unwilling to discuss sexuality and STD-related issues openly or refuse to have the issue appear in the public arena. Such reluctance has devastating consequences for STD prevention efforts. Open and
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--> frank communication and the sharing of information regarding sexuality and STDs are essential to preventing high-risk sexual behavior. In order to change behavior, Americans have to feel comfortable discussing sexual health issues; open communication between parents and children, between sexual partners, between teachers and students, and between health care providers and patients is essential. The secrecy surrounding sexuality impedes sexuality education programs for adolescents, open discussion between parents and their children and between sex partners, balanced messages from mass media, education and counseling activities of health care professionals, and community activism regarding STDs. Opponents of sexuality education programs for adolescents are likely to deny the possibility that their children are sexually active. Unfortunately, denial often eliminates the possibility that parents will communicate with their children regarding STDs, and this encourages high-risk behaviors. Children in these families are likely to get their information, which is often inaccurate, from other sources. Lack of comfort with open discussions of sexuality also makes open communication regarding sexual history and negotiating safer sex difficult. In addition, this discomfort has also resulted in a mass media that has not been involved in promoting healthy sexual behaviors. This industry commonly acquiesces to the public's fascination with sex, yet is generally not willing to incorporate and promote factual information regarding STDs and protective behaviors. Furthermore, discomfort and secrecy among health care providers adversely affects the delivery of health services. As a result, many clinicians do not identify potential problems or are ineffective in counseling their patients regarding healthy sexual behavior. Finally, secrecy hinders community activism for STDs. An effective STD prevention program should focus on overcoming all barriers to open communication. Despite or because of the secrecy surrounding sexuality, adolescents and young adults are becoming increasingly sexually active. Better research is needed to track the problem of STDs and identify possible solutions; much of the data available in this area are seriously outdated or incomplete. There is a compelling need for further training of clinicians, educators, and researchers in the area of human sexuality. The poor understanding of STDs among Americans strongly supports a coordinated campaign to improve knowledge and awareness. References AAP (American Academy of Pediatrics), Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children. Pediatrics 1991;87:254-60. AMA (American Medical Association), Council on Scientific Affairs. Health care needs of homeless and runaway youths. JAMA 1989;262:1358-61. AMA, Council on Scientific Affairs. Health care needs of gay men and lesbians in the United States. JAMA 1996;275:1354-9. Amaro H. Considerations for prevention of HIV infection among Hispanic women. Psychol Women Q 1988; 12:429-43.
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