Category Archives: STIs

they’ll like us when we win

Trigger warning. Discussion of attitudes supportive of sexual violence.

Here’s a TED talk of Melinda Gates talking about how Coke does things that human services can learn from. Coke, she tells us, uses real-time data, local entrepreneurs, and aspirational marketing.

What she doesn’t mention is that Coke has a product that is chemically addictive (caffeine) and filled with glycogen-ready sucrose. Human bodies/brains respond to table sugar in much the way they respond to cocaine. I’m pretty sure Coke doesn’t need to make us feel good with aspirational marketing, because it makes us feel good with sugar and caffeine.

In contrast, when it comes to prevention interventions around sex, it really doesn’t matter how “aspirational” your marketing is or how good your data are: condoms interfere with pleasure. They require a skillset separate from (and potentially interfering with) the skillset for being good in bed and enjoying sexual pleasure. They do. Condoms don’t feel as nice as skin, and anyone who says differently probably works for a condom company or a public health office.

I’m a sex educator; it’s my job (among other things) to persuade people to use condoms correctly and consistently. What are the good things and the not-so-good things about using a condom?

Good things: not getting a disease, not getting pregnant.

Not so good things: fumbling around, feeling embarrassed, potential loss of erection, making your partner think you don’t trust them or that you think they have a disease or that you cheated on them or think they cheated on you, not to mention reduced sensation.

Young people in particular have a hard enough time communicating about sex, but add to that communicating about condoms and you just have a shitshow.

What is there but fear – and POWERFUL fear, to overcome the perceived unlikelihood of negative consequences – to force someone to use a condom, given that laundry list of hassles and worries and angst?

Well.

This fell into my head after a series of conversations with a variety of people that can be summed up this way:

In Europe, there are small pockets of immigrant, Muslim men who believe that women who wear t-shirts and show their knees are no better than they should be and it’s completely fine to do anything you like to them, including sexually harass and assault them. Just small pockets of them, but they’re there, and they’re convinced by their cultural beliefs (emphatically NOT their religious beliefs or their families’ beliefs, but by specific cultural rules of men in impoverished and marginalized communities) that what I call violence against women is completely acceptable.

So tell me, Melinda Gates, what does Coke have to teach us about changing that? What aspirational marketing, local entrepreneurship, or real-time data will convince these men that their behavior is in fact morally reprehensible, not to mention criminal?

This, at a time when my mandatory sexual harassment training tell me that if a coach touches his athlete in a way that makes her feel uncomfortable and asks her personal questions that make her feel uncomfortable, this might not be harassment if (a) it’s common for coaches to do these things (b) he treats all his athletes this way or (c) other athletes don’t agree that she’s being harassed.

That’s what MY LAWYER is telling me.

(NB: If it’s common for coaches to touch their athletes in this way, then there’s systemic abuse happening; if this coach treats all his athletes this way, then he’s a serial perpetrator. And if the other athletes don’t agree she’s being harassed, they’re participating in rape culture, with its victim blaming/survivor stigmatization, its gender stereotypes, and its rape myth acceptance.)

Sometimes you can’t be nice. Sometimes you just have to make laws and enforce the hell out of them and manage the inevitable resistance that arises, and eventually you WIN and then people settle into a new normal.

Toby on West Wing said it: They’ll like us when we win.

Condoms are not the answer to STIs: cures and vaccines are the answer. People can’t be relied on to protect their long term interests in the face of short-term loss.

And collaborative, developmental conversations are not the answer to changing the culture of objectification of women: shaming and imprisonment are the answer. People can’t be relied on to retain respect for others when everything in their culture and their meta-culture tells them that others are not really human.

There are days when I’m not interested in creative solutions or getting the buy-in of the stakeholders. There are days when I just want to blow people off the face of the earth. They’ll like us when we win.

how a sex nerd copes with the primaries

A mildly sadistic friend of mine posted this on my Facebook wall:

It could piss me off if I let it. The idea that this dude might be taken seriously as a candidate for president is either laughable or COMPLETELY FUCKING TERRIFYING, and for my own mental health I simply MUST choose to laugh. I took the 2004 election very seriously and it nearly killed me. I’m not exaggerating. When Kerry conceded, my knees failed, I collapsed on the couch and started oozing fluids from every orifice on my face. It was exactly like that scene in “Transamerica” where Felicity Huffman loses her shit and sobs, gasping like she’s been socked in the gut, with drool hanging like stalactites from her wide-open mouth. I spent three weeks after the election unable to taste food or write complete sentences or sleep more than 4 hours in a row. I lost almost 15 pounds. (“Emily, you look great! How’d you do it?” “Stress and depression.” “…Oh.”)

So for my own wellbeing, I’m allowing myself to experience this video as I would a quiz show where I, a member of the viewing audience, know the answer, and the person on the show is fumbling and stumbling and guessing and flubbing. Meanwhile I’m shouting the answer* tauntingly at the screen and calculating how many washer-drier combos I would be winning if I were on the show.

If I viewed it as a Q&A with a guy who stood a chance at being President, I’d throw my computer out the window and then bash it to pieces with a sledgehammer. I’d rage and sob and scream. I would spend an awful lot of time with my computer away at tech support and an awful lot of money on therapy and antidepressants if I were paying serious attention to the primaries. So I’m ignoring them as best I can, and viewing what I can’t avoid with the detachment of a Buddhist.

And that is how a sex nerd copes with Republican primaries. Ignorance and detached humor.

I must add, if he had played this for the laughs it got:

“I’m just gonna tell you from my own personal life, abstinence works.”

I might have found myself actually liking Perry, if for nothing else, for his comfort with his own lack of sexual appeal. Self-awareness is a good trait in a candidate.

Alas, he failed to notice the humor. He probably also failed to note that he could very well be conflating “not having intercourse” with “not having a vagina.” Nothing beats being male for making sure you don’t get pregnant, so here’s a sex nerd top sex tip: if you’re going to choose abstinence as your pregnancy prevention strategy, choose a back-up method like not having a vagina and uterus, just in case you accidentally have sex.

*Teaching abstinence doesn’t work to prevent pregnancy and STIs for a large number of reasons, but one important and rarely appreciated reason is that abstinence as a harm reduction strategy has the highest failure rate of any method – very approximately 50%. People just SUCK at using abstinence. You think they’re bad at using condoms? You should see them try not to have sex!

the other problem with risk

I mentioned once that there was something important to say about risk and perception at the individual level versus the population level. Let’s try saying it this way:

Every time I put my shoes on, my dog gets excited.

“No, Mr Pants, I’m just going to work. What’s the matter with you?” I say.

Why does he get excited when I put my shoes on? I mean, he only gets to go out, oh, definitely less than half the time that I put my shoes on.

But.

Me putting my shoes on happens EVERY TIME he goes out. Only my touching the leash is a better predictor of getting to go out.

So from one perspective, my putting my shoes on only predicts his going out less than half the time. But from another perspective, going out is predicted 100% of the time by my putting my shoes on.

When you think about this concept in terms of sexual health, it’s kind of inside out. Like, suppose you use a condom maybe half the time, and yet you still don’t get an STI. What that teaches you is that NOT using a condom is just as predictive of getting an STI as using a condom is. Dig? You may know intellectually that condoms prevent lots of STIs, but as far as your direct experience goes, condom use isn’t associated with prevention.

Maybe the dog isn’t a helpful example. Taking drinking. Now, on my campus 80% of the drinking that happens is beer and wine, but 100% of the medical emergencies related to alcohol are related to liquor. So at the population level, you vastly increase your chances of having things go seriously wrong if you drink liquor.

But look at it from the individual perspective. If something like 500 students each weekend consume liquor (these are imaginary but realistic numbers). And about two students per month end up at the hospital (fictional but realistic). So you’ve got 8 nights, 500 students each night and maybe two emergencies. That’s a VERY low correlation, right, so from the individual point of view it’s easy to think that the risk is very low. Which it is – except in comparison to not drinking or drinking only beer or wine. This other group is much larger and has zero emergencies.

It’s about perspective, and we humans are deeply irrational when we’re deciding how to assess risk. Somehow we believe we will never be struck by lightening but, you never know, we might win the lottery, even though the odds are similar.

The odds of getting an STI from any individual sexual event aren’t terrifically high – something like .004% for HIV, if I remember correctly (which I might not). But when you add a condom, the odds go way, way, way, way down. And the thing is, once you have HIV, you, like, have HIV. Which changes your life.

But it’s not compelling for me to stand in front of students and say, “You’ve got a minute fraction of a percent of chance of getting HIV, if you have intercourse, so use a condom every time in order to make it a vastly smaller minute fraction of a percent.”

It’s a problem, friends, this deep inability we have to understand the nature of risk.

stupid ass bullshit in the NYT

This may well be the dumbest thing I’ve ever read in the New York Times.

There’s too much specific stuff to deal with, so I’ll just skip to the end. He writes:

Liberals argue, not unreasonably, that Planned Parenthood’s approach is tailored to the gritty realities of teenage sexuality. But realism can blur into cynicism, and a jaded attitude can become a self-fulfilling prophecy. Social conservatives look at the contemporary sexual landscape and remember that it wasn’t always thus, and they look at current trends and hope that it doesn’t have to be this way forever.

Let me just rewrite that as it SHOULD be:

Planned Parenthood’s approach is tailored to the gritty realities of the politics of teenage sexuality. They emphasize condoms and contraception because social conservatives fear the possibility that teenage sexuality could be beautiful, meaningful, pleasurable, and self-actualizing, and that fear means PP couldn’t get funding for education that talked about self-pleasuring, talking with your partner about pleasure, or understanding the role of pleasure in a sexual relationship. Social conservatives look at the contemporary sexual landscape and fear that teenagers having sex is inherently dangerous, emotionally and morally.

And social conservatives are afraid of women, especially women’s sexuality. They fear the change and that would come if girls measured their own worth by something other than their ability to sustain relationships with boys, so PP could never get funding for programs that taught women about how to say yes, how to know what they want in bed and in life, how to be women and agents of their own sexuality; and PP could never get funding for programs that teach boys about the context-dependence of women’s sexual response or the importance of the clitoris or the vital, crucial importance of listening to a girl’s words.

Finally, there is a correlation between depression and earlier “sexual debut” in girls. That’s true. There is also a a correlation between sexual abuse and depression in girls and sexual abuse and earlier consensual sex, and between insecure attachment style and depression in girls and between insecure attachment style and more sex partners. … But… obviously the early sex is what’s causing them to be depressed, not the poor parenting, the abuse of their bodies, or, let’s be real, the unequal access to educational and economic opportunities that create an environment where a girl’s only way to judge her value is in her relationships to boys.

The best “abstinence-based” sex education in the world? Girls’ sports. Give girls something to do, a way to gauge their own worth, other than having sex with boys.

You want teenagers to start having sex later and have fewer partners? So do I. You want the sex they have to be in the context of emotionally engaged relationships with a commitment to honesty and monogamy? So do I!

But you conservatives are creating the sickness, creating the disease of “teenage promiscuity,” the way footbinding shapes a foot. If you allow it to grow, if you give it space, it will become beautiful, natural, healthy.

The new sex, the sex of the twenty-first century, is about pleasure. Even for teenagers. And that’s a revolution.

top hat: lesbian pro

Two questions asked similar things, plus I recently had a conversation with a student about it, so it might be time to write a post about it.

I think I’ve only ever met 1 lesbian who claims to regularly use protection with women. What’s your view on safe sex in lesbian relationships?

and

How do lesbians protect themselves against STIs when they are dry humping or scissoring?

Well it’s a big deal, and it gets really political. The lesbian community has protested that they’ve been neglected in public health interventions around, for example HIV. And I want to be explicit that it definitely is possible to transmit HIV during genital-to-genital contact between women. But it’s not easy. It’s also possible to transmit HIV during cunnilingus – but it’s really not easy.

STIs are transmitted via contact with the fluids and genital skin of a person who is infected. Therefore:

The first and best way not to contract an STI is for you and your partner to be tested. If there is no infection and the two of you are only being sexual with each other, no need to use pro. Super.

If one of you has an infection, or if you’re not in a monogamous relationship, you need to decide what degree of risk you’re comfortable with. Your next choices about protection are based on the trade-offs of good things and not so good things.

The technical part of your range of options has to do with preventing contact with infected or potentially-infected fluids and skin. The emotional part of your range of options has to do with your comfort level with talking about and using protection.

The skin-to-skin infections are probably the greatest risk with something like scissoring, where the genitals are in direct contact. The protection solution? Saran wrap. Really. Not the microwavable kind, just the regular kind. It’s non-porous, you can pull big sheets that cover everything you need to cover, plus it’s totally clear so you can see through it and it has no taste (unlike latex) so it’s great for oral as well.

Now, many of you may now be thinking, “But look, I’ll never really do that. It’s embarrassing and awkward and I’m just not going to pull a roll of Saran wrap out from under my bed.”

And that’s fine. Just know that if you engage in that behavior without a barrier when one of you might be infected, there’s a risk of infection. Sometimes people are more comfortable with the risk of infection than they are with the embarrassment of introducing a barrier. That’s totally up to you. (Must write post about human perceptions of risk.)

[EDIT: I wrote about about human perceptions of risk.]

If you’d like to reduce risk without using a barrier, then behavioral methods are your go-to strategy. Just avoid stuff like scissoring and humping, so there’s not direct contact with her genital skin and fluids to your genital skin and fluids. You don’t even necessarily have to explain what you don’t want to do or why; you just have to do the stuff you feel safe with and not do the stuff you don’t feel safe with.

Behavior ideas: Manual sex is quite low risk (as long as you keep your juicy hands off YOUR pooter) and so it’s a great option if you don’t know your partner’s history or monogamy or if one of you is infected. Mutual masturbation -watching each other as you simultaneously masturbate – is quite low-risk and can be very, very sexy. Oral sex has somewhat higher risk, since the various bacterial infections can be transmitted orally (and you do NOT want Gonorrhea of the mouth!), but it’s pretty dark low-risk for herpes and especially for HPV.

And of course there’s the option of, like, not having sex with someone you don’t feel comfortable enough with to talk about medical and sexual histories, protection choices, and behavioral preferences. But hell, this is the real world, right? You want to have sex and you also have a lot of cultural crap in your head about it, so what’s a girl to do?

Final note: my understanding of the term “dry humping” is that it’s humping with your clothes on… is that wrong? Without clothes, it’s just good old humping, nice and wet. Clothes on, no need for extra pro. Clothes off, see above.

keep it up

I’m finally beginning to come up for air after the inevitable pummelling that is the first part of the fall semester, which means plowing my way through an embarrassingly large backlog of emails.

Apologies to everyone I have neglected for, um, months.

Anyway, one guy sent me this video, which I just love but it turns out I can’t embed, so I hope you’ll go through to the trouble of actually clicking on that link there.

Or on this one.

Did you click?

Excellent! Then you’ll know that it heaps praise and pours lauds on the gay men out there who don’t have HIV, who do the pain-in-the-ass stuff it takes to prevent getting HIV all while having satisfying sex lives. As anonymous dude who sent it to me says, “it applies to all sexually active folks, not just gay men”

And as Mark says, keep it up. :o)

pleasure as empowerment

Here’s a thing from a description of an adult sex education program:

We do talk about what turns people on, not by way of giving a list of turn-ons, but we talk about the fact that different people are turned on by different things, and different parts of the body excite people differently. We let them appreciate the fact that it wouldn’t help to compare their spouses to previous sexual partners and assume that a particular type of foreplay or touch or part of the body which turned on a previous lover will necessarily have a similar or the same effect on the spouse. There is a need to understand the uniqueness and individuality of everyone and take time to understand each other’s body and what gives pleasure

Holy crap. Don’t you want to attend that class? Don’t you want to hear what they have to say?

Well, you have to go to Nigeria to hear it.

It’s from the Community Life Project, a “Participatory, community-based, demand-driven approach to provide reproductive health and HIV/AIDs education and promote family and community development.”

The idea here is that sexual pleasure is empowering. It’s an issue that Contestations took up recently. Here’s a synopsis, but I encourage you to read the whole thing:

Sylvia Tamale writes that the discourse of pleasure, of “erotic is power,” helps African women to reclaim sexual autonomy from the forces of patriarchy and religious fundamentalism.

In different ways, both Sonia Correa and Petra Boyton warn that pleasure can be just as oppressive a narrative as those that underscore violence.

Li Yinhe very simply says that the cultural tradition of China is that women should be utterly non-sexual, and that tradition is unfair. “Women have a right to sex, and should be able to enjoy the happiness of sex, not just serve men sexually, or have sex for reproduction.”

As Pinar Ilkkaracan says:

women from all socio-economic levels perceive the autonomy over their bodies and sexuality to be an indispensable part of their human rights and one of the most significant pre-conditions of their empowerment.

Me, I say that when you teach about safer sex from the point of view of pleasure, you get better results. If you don’t acknowledge that people have sex because it feels good and they like it, they won’t pay attention to you. Why should they? What do you understand about why they have sex? From a pragmatic viewpoint, acknowledging the importance of pleasure, when to teach Americans about sex at least, is crucial to effective education.

But even more, the acknowledgement that women have a right to pleasure implies, necessarily, that they have a right to control their own bodies. There are plenty of cultures left in the world where women’s bodies are considered to be in the public domain, accessible to whatever man decide to avail himself. Too, the perception of “nice, clean” middle class women as non-sexual results in the sexual exploitation of poor women.

It’s an argument that I find self-evident, but lots of people struggle with it. “Why is pleasure important when there’s, like, AIDS and fistulas and stuff?” Well. Women are sexual; they have desires and arousal and orgasms; they have bodies that can touch and be touched. Women get to be in control of their bodies, as men get to be in control of theirs. Women get to control their reproduction and when they have sex. Women’s sexual pleasure is a right. Recognizing this when we teach about sex makes sex education more effective and builds a culture of sexual agency for women, gives women power.

Pleasure as empowerment. See?

For more examples, have a look at Global Mapping of Pleasure, which identifies sex positive harm reduction interventions around the world.

by request: to the teenage boy in your life

Dear Heterosexual Teenage Boy,

I’ve never been a teenage boy myself, yet I have a lot of sympathy for the difficulties inherent in being flooded with testosterone and not having any idea what to do with it. I can appreciate the bafflement you must experience when confronted with girls, who seem strangely alien.

I’m here to help.

Here are some things you need to know.

IMPORTANT FACTS ABOUT GIRLS

Important Fact #1: Girls are Like Boys, Minus the Penises
An important thing to remember is that girls are not from a different planet, nor are they even a different species. They’re just people, they’re just like boys, except with vulvas instead of penises.

Mainly you need to remember this when you’re trying to figure out what a girl is thinking. See, if you didn’t know what a BOY was thinking, how would you go about finding out? You might ask him, right? The same goes for girls. There is no decoder ring, because there is no need for one. Girls are like boys, only female, ya know. They’re people.

All that stuff you see in movies and TV about how girls don’t like it if a guy has to ask? That’s bullshit. She would LOVE for you to ask what she’s thinking.

Important Fact #2: “No” means No. “Maybe” means No. Silence means No. “YES” means Yes.
You should believe what girls say. When they say “No” or “Stop” or “I’m not ready” or “I’m not sure” or “This doesn’t feel right” or “Um…” or nothing at all, that means NO. STOP. Anything other than “YES” or “That feels good” means NO. She might say it quietly or gently because she wants to be nice and not hurt your feelings because she LIKES you but just isn’t ready for whatever you’re doing. Listen to her WORDS.

I can tell you from a position of great authority that good sex only happens when BOTH people are into it. You want her to be into it, right? You want her to enjoy being sexual with you? Of course you do!

How can you tell if she’s enjoying it? Only her WORDS can tell you that. So listen to them and only do stuff she says YES to. Not sure she’s into it? See Important Fact #1, and also: doubt means don’t.

Important Fact #3: Girls Might Be Even More Confused about Sex Than You Are
Girls get really conflicting messages about sex from society. On the one hand they’re supposed to be really sexually desirable and attractive and they’re supposed to want sex, but on the other hand they’re supposed to stay virgins until they get married and be Good Girls. On top of that, girls’ bodies are less straightforward than boys’ in terms of sexual response.

I mean, you’ve got this handy barometer to tell you when you’re turned on. You’re familiar with your genitals. You’ve probably already had an orgasm. None of those things are necessarily true for girls. Their genitals are tucked away, hidden, and they don’t make a tent in their pants when a cute guy walks by. Not having a penis makes things different for girls. More complicated.

Look I’m gonna use a stereotype here, but maybe it’sll get the point across:

You know how sometimes you might feel like she knows all this stuff about emotions and relationships and you’re like, “When did she LEARN all this?” Sex is kind of like that for her. She’s still learning a bunch of stuff that you’ve already figured out because you have a penis.

So be patient with your girlfriend, as she is patient with you learning the emotional stuff. Arrite.

IMPORTANT FACTS ABOUT CONDOMS

Important Fact #1: Condoms work – if you use them.
Condoms are the most effective way to prevent STDs for people who are sexually active. They’re also the most effective male-controlled contraceptive method. Don’t want to have a baby? Use condoms. Use them correctly and consistently.

Put the condom on BEFORE you ever put your penis in her vagina, and keep it on until after you ejaculate and withdraw. Never deviate from this.

Important Fact #2: Be Nice to Your Condoms
Latex degrades in heat and cold, and when latex degrades, your condom fails. And a condom can LOOK intact when it actually isn’t, so be NICE to your condoms and they’ll be nice to you.

How?

Don’t keep your condoms in a glove compartment in the car, and don’t keep a condom in your wallet for more than a few weeks.

Be sure it’s in good shape before you use it – there should be an air bubble in the packet.

Pinch the tip of the condom when you roll it on, to leave a space at the top for your cum to land in.

Never open a condom packet with your teeth. You can use scissors ONLY if you scooch the condom down to the bottom half of the packet with one hand while you cut with the other. (HINT: hold your hand out the way you would hold a cigarette, with your index and middle fingers extended. Insert the condom packet between your fingers so that the foil wrapper go through, but the condom scrunches up under your fingers. Now turn your palm over and cut across the top of the foil.)

Important Fact #3: Keep Your Fluids to Yourself
The point of condoms is to keep one person’s sexual fluids and skin from touching the other person’s sexual fluids and skin.

If you’ve been touching your own or your partner’s genitals, you should wash your hands before you put the condom on. Otherwise you get all the sex juice on your hands on the outside of the condom, and that defeats the purpose.

After you ejaculate, hold the base of the condom as you withdraw, so it doesn’t fall off. Tie a knot in the top and throw it in the trash. DON’T flush it.

So there you have it. I hope some of that is useful.

attachment, safer sex, money, equality, justice, etc

I’ve been writing lectures about safer sex and so I’ve been thinking about this fascinating stuff to do with the relationship between safer sex behaviors and attachment style.

Briefly, safer sex is sexual decision-making and behavior that decreases (not necessarily eliminates) risk of STI transmission and unwanted pregnancy. The efficacy of prevention interventions, indeed, is measured in terms of rates of STI transmission, unwanted pregnancy, and “sexual debut,” which is one of my favorite phrases ever. (The reason sexual debut is an outcome measure is that starting to have sex later in life is strongly and consistently correlated with better sexual health outcomes.)

Attachment style predicts pretty much all the things you might expect:

  1. Anxious attachment is associated with not wanting to use condoms because it puts a barrier between you and your partner; avoidant attachment is associated with more consistent condom use for the same reason.
  2. Securely attached adolescents are the most likely to have monogamous long term relationships, fewer partners, and better communication around safer sex practices.
  3. Anxious style folks will use sex as a way to allay fears of abandonment, and they report preferring the affectionate aspects of sex to the plain old sexual aspects.

Weirdly, among adolescents, anxious attachment is globally protective for boys but not for girls, in terms of not-so-good health consequences related to sex. Avoidant attachment protects girls but not boys from those consequences. Secure attachment is better than either insecure attachment style, in both boys and girls.

Secure attachment being associated with the best sexual health outcomes, we’ve got a class disparity on our hands, since poverty negatively impacts attachment for a variety of reasons; kids who grow up poor are more likely to develop insecure attachment styles. (The “why” of this is extremely complicated and whole books have been written about it. See, for example, Culture and Attachment: Perceptions of the Child in Context.)

So negative health outcomes are perpetuated by socioeconomic status not just for the straightforward reasons of lack of access to services, education, and other resources, but also because of the emotional differences of living a life of want compared to a life of privilege.

I’ve mentioned before that human social systems are complex, in the purest sense of the word and that recognizing that complexity will help us to create positive change.

This is an example of that. Just giving people condoms won’t help if they don’t know how to use them; and even knowing how to use them isn’t enough, if they’re not motivated to use them. In order to change the decisions people make, you have to address the environment in which they become decision-makers.

Want people to have safer sex and/or less risky sex? End poverty. (Apparently we need more reasons to end poverty, because it’s not a self-evidently important goal in itself. We. Are. Morons.)

EDIT: Remarkably timely New Scientist article with an evolutionary angle on the relationship between socioeconomic level and sexual behavior.

of warts, sores, and testing

I was chatting yesterday with a physician about recommendations and guidelines for testing for STIs (as you do). He explained the new guidelines for Pap smears and I told him that the Syphillis/Facebook correlation is bunkum. It was a nice time. Anyway.

For 10 years, I taught young women to get annual exams starting when they were 18, whether they were sexually active or not.

Now the guideline is to start at 21, test every OTHER year until you’re 30, then test every 3 years as long as the results are normal.

Why?

Because learning that you have HPV causes more drama than it warrants; young women in particular will clear the virus in a year or two and will never have any symptoms. Yes they may transmit it to partners, who will transmit it to their partners, but those partners and partners of partners will also have no symptoms and will clear the virus within a year or two. And the real kicker: it takes like 10 years for HPV to cause cancer, apparently, so testing every 2 or 3 years will still get you an early diagnosis.

My own experience bears out the potential benefit of these guidelines. When I was diagnosed with HPV 700 years ago, I felt like someone had kicked my chair out from under me; remember, I’ve been a sex educator for longer than I’ve been having sex, so to be diagnosed with an STI felt like both a personal and a professional failure. But it isn’t – it’s just a virtually inevitable consequence of having sex.

Then I had a colposcopy and a painful biopsy that put me in bed for 24 hours afterward. I got up in the middle of the night to pee, looked at myself in the mirror, and saw a white-lipped, hollow-eyed horrorshow looking back. My bloodflow, even 12 hours after the procedure, was so targeted to my cervix that I had to crawl back to bed on all fours so I didn’t pass out en route. Then I lay in bed for an hour, singing the complete score of “Joseph and the Amazing Technicolor Dreamcoat” to myself whilst waiting for the ibuprophen to dull down the pain enough for me I to go back to sleep. It was a memorable night – equal parts laughable and pitiable, “like a wounded rabbit that keeps farting,” as David Mitchell puts it.

I had follow-up Paps every 3 months for a year, then every 6 months for two years, and never again had an abnormal result.

If I hadn’t had a Pap that year, I would never have known about it.

So I’m thoroughly convinced. I’ll miss my entertaining nurse practitioner, who tells me about her son’s drinking (she knows I do alcohol education on campus), but ever since the biopsy for some reason I’ve had an aversion to metal instruments up the vag, so. See you in 3 years, babe.

Another issue of course is the accuracy of these tests. Herpes, for example, has a high rate of false positives and, the physician pointed out to me, the doc’s not going to do anything about it anyway. With both HPV and HSV, latex is, well, partially protective, but these viruses are transmitted through skin-to-skin contact, so if you’re having genital-to-genital contact it would take a LOT of coverage to ensure protection.

The realistic strategy? Just assume everyone has HPV and herpes, and relax.

Which feels wrong and crazy to my students; the population I work with gets really FREAKED OUT about STIs. The idea of living calmly with an infection is utterly foreign to them.

I’m an educator. I’m not a medical professional, I’m not a counselor or therapist, I’m not even a researcher. A big chunk of my role is to serve as liaison between medical providers and the public, helping folks understand when to get tested, what to get tested for, what the results of those tests mean, and what to do about them.

I struggle each time to find a balance between caution and calm. Yes, use condoms. Yes, get tested as appropriate – but you don’t actually need a full screen for everything. You don’t even need to worry too much about a positive result. I worry about motivating students to protect themselves, while reducing fear, stigma, moral judgments, and shame that accompany Infection.

Because contrary to what “House” viewers might think, not everyone who has an affair (“concurrent partners” in public health speak) gets neurosyphillis, ya know? There is no system of crime and punishment in sex. There are just networks of people and the movement of critters through those networks.

How do I say, “Protect yourself, but don’t worry”? I still don’t know, after years of trying.

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