A couple of days ago, I received email on behalf of someone who is in a committed, closed, and monogamous relationship, who had STI screening before engaging in intimate contact with their new partner(who had also had STI screening prior to their first encounter). Both partners came up clean, but recently, they have discovered that chlamydia, herpes, and HPV were somehow introduced into their relationship and they aren’t sure how or when. Neither partner has been with anyone else since they were each tested before they became a serious item — how did this happen? And what do they do now?
I feel for this person, even though I don’t know who they are, because the initial shock feels awful and they now fear that they are damaged goods that no one will ever want to be near again, because of widespread stigma associated with STIs. I’ve been there myself. It was incredibly brave of them to seek help. But their tormented feelings are optional, and this blog post is about why (in case you don’t want the highly detailed and intimate version I’ve just linked to — which was subsequently trolled by the very person it addresses). I’ve also added a couple of brief comments about the serious repercussions of stigma, which include promoting the spread of misinformation, arrogant attitudes, and the very STIs that are the subject of the stigma in the first place. I’ve published this piece of writing in an effort to help circulate a more responsible social attitude towards human sexuality (STIs being one of the risks of engaging in sex at all), and to help reduce misinformation, ignorance, and stigma around chlamydia, herpes, and HPV in particular.
I am sex-positive and do not believe for a minute that people with STIs are in any way less deserving of the right to love who they want, how they want. I also believe everyone is ultimately responsible for managing their own sexual health and well-being.
The information in this blog post is a compilation of approximately ten years of direct personal experience and very mildly badgering doctors and nurses for information — one of whom opened the Merck Index of Sexually Transmitted Diseases to the entry on chlamydia and then handed it to me to read the night before I received antibiotics. I also sought information for years through internet searches, workshops on safer sex and prevention of sexually transmitted infections (such as one with an outreach nurse from the BC Centre for Disease Control), and even by stealing more than my fair share of the Journal of Obstetrics & Gynecology Canada from the recycling pile at the doctor’s office where I worked for nearly a year before returning to school with the aspiration of becoming a doctor myself.
I am not a doctor, or even a nurse, and this post is not medical advice. Any error in the reporting of what I’ve learned about this topic is entirely due to my own ignorance and/or poor choice of words. I strongly encourage you to practice safer sex, get regular STI testing (and regular pap smears if you are a Person With A Cervix), and talk to your doctors and/or nurses if you have questions about your sexual and/or reproductive health.
A Quick Note About Safer Sex
By referring to safer sex barriers, I am referring to the use of condoms, gloves, and dental dams (or non-microwavable cling wrap in a pinch in place of a dental dam — microwave-safe cling wrap is porous and not a substitute). A condom is one type of barrier, but it is not the only one, and does not prevent transmission of STIs through cunnlingus, analingus, digital penetration, or fisting (not to mention skin-to-skin transmissible infections).
If you don’t have barriers and/or don’t have the option of waiting to get tested together first (if it’s just the right time right now), use a sex toy instead. Non-porous materials I’ve personally seen sex toys made out of include glass, pyrex, steel, medical grade silicone, and even gold. However, many toys made of thermoplastics feel and look like silicone but are actually porous and cannot be adequately sanitized if they are used in someone’s butt. So if it’s going to be used in someone’s butt, put a barrier between the toy and the person it’s being used on. The same applies for peace of mind if it’s yours but not being used on you, or if it’s not yours and is being used on you. All you need to wash toys, between whoever they are being used on, is a mild hand soap and warm water. No soaking, boiling, or chemical cleaners required, as any STI that can survive exposure to air can’t set up a colony on a sex toy under running water.
First and foremost, this one is 100% curable. It’s highly embarrassing and utterly wretched for the 2% of exposed sexually active adults who become immediately symptomatic — believe me, I know that from first hand experience. For the other 98%, whose symptoms first manifest 8 weeks after exposure, it’s roughly the worst case of two-week bronchitis you’ll ever have, and they’ll very likely have absolutely no idea how this relates to what’s in their pants (or their partner’s pants). On top of that, it’s highly embarrassing and utterly wretched in between episodes of bronchitis, for those who have a vulva. Either a particularly astute physician or a persistent patient will get to the bottom of this in a matter of time. In the mean time, it’s contagious, and it spreads through contact with any bodily fluid other than saliva.
Because so many people are asymptomatic for so long, and because those symptoms that finally emerge are seemingly unrelated to sexual intimacy, it tends to be transmitted from one person to another while there is no apparent problem. It is transmitted through unprotected oral sex, penile-vaginal sex, and anal sex. Once detected, it is treated with antibiotics and clears up 4 weeks after the first dose. There are two things to note, however. First, testing for chlamydia is expensive, and thus physicians tend not to include it in STI testing unless specifically requested — instead, testing against the possibility of gonorrhea first (and if a patient is still symptomatic after testing negative, the physician may simply prescribe the antibiotics without even sending the patient for a test to confirm the presence of chlamydia). And second, during the 4-week period starting from the first dose of the antibiotic, the body is shedding live chlamydia and is thus still contagious (even if you feel better and your symptoms clear up, as they typically do within a couple of days).
These are all reasons why chlamydia is the most common STI. That one can seek STI testing from their family physician and be issued a clean bill of sexual health is fabulous and I highly encourage it as a regular part of a healthy sex life. I also highly encourage asking that a test for chlamydia is added to the papers for the lab, or asking to see the print-out (which lists what was tested for). Alternatively, or if your physician seems reluctant, find out if there is a clinic near you specializing in sexual health, such as at your local center for disease control or an organization that caters to LGBTQs (you don’t have to be queer to access services). I’ve been lucky, in that since I found out all about chlamydia, I’ve had the good fortune of having cooperative doctors and nurses at a sexual and reproductive health clinic in one city (Edmonton, AB), and doctors and nurses testing for chlamydia by default in the next (Vancouver and all of the Lower Mainland, BC).
First and foremost, while herpes is not curable, you were probably repeatedly exposed as a child. It is spread through contact with saliva (most common means of transmission) or other bodily fluids from a carrier in an active stage of viral shedding (which can be symptomatic but is not always). A vast majority of people carry herpes in their bodies, and were exposed before the age of 10 through completely normative contact with an adult carrier. Neither funny business nor traumatic events are necessary for exposure. The majority of carriers do not exhibit symptoms, even as they go through reactivation and shedding cycles just like those carriers who are symptomatic. My mother started getting cold sores on her lips from shortly after she started having her period, yet my father, my two sisters and I are all asymptomatic even though we’ve all certainly been repeatedly exposed for decades.
Symptoms are generally annoying and somewhat unpleasant lesions (cold sores, canker sores, heat blisters, and/or small localized ulcerations) on the very edge of the lips, or sometimes even somewhere inside the mouth, anus, or vagina. Most people who experience lesions inside their mouth or another body cavity won’t know it unless a dentist or doctor tells them about it. Some people experience such difficulty with their symptoms that they take a medication to prevent flare-ups, but they can still occasionally become contagious or experience symptoms, even if they take the medication with religious dedication. Some people even experience a painful herpetic ulceration of the eye that can be treated the same day with antiviral eye drops, generally clearing up within a couple of days without lasting damage and allowing them to move on with their lives (this is also true of people who, like myself, caught chickenpox, either before the vaccine was available or because they weren’t vaccinated). Modern medicine is wonderful, but it has not yet determined why only some people experience herpes symptoms.
Available testing consists of—wait for it—telling you upon symptomatic presentation that you have herpes. Kind of underwhelming and not in the slightest bit scientific, but there it is. An estimated 80% of everyone at any given time is a carrier of HSV, simply because so many people are exposed so often, from their early childhood and throughout their life in day-to-day interactions with other people who were exposed as children. Testing people for HSV merely tells us what we already know: lots of people have it. It doesn’t tell you if you are actively contagious or when, and on what part of your body you would expect symptoms to appear or even if you will be symptomatic. Some physicians will take a swab of an active lesion to test where it showed up on the body first (i.e., type 1 shows up in or on the face first, and type 2 shows up in or on the genitals first). Continued stigma against the very idea of herpes is just perpetual nonsense, but with the particularly harmful side effect of creating and maintaining social barriers against regular STI testing (which is paradoxical, given that no one is ever tested for HSV).
HPV (Human Papillomavirus)
First and foremost, though HPV is not curable, many people who are exposed as very young adults eventually eliminate the virus without ever requiring treatment for their symptoms. There are over 80 strains of HPV, and of the 4 that are the most hazardous to women’s health in particular, there is now a vaccine available. Ten years ago, you couldn’t even find accessible information about it, and now you can protect yourself from the 4 most dangerous strains before you even start having sex (although at this point, if you have already had sex with someone who was not at the time a virgin, the vaccine arrived a little late for you). HPV is spread through skin-to-skin contact with a carrier, who may or may not appear symptomatic — some strains manifest in lesions that are not visible to the unassisted eye. Using safer sex barriers can help prevent transmission but is no guarantee of protection, as lesions can and do appear on parts of the body that are not covered by these barriers.
Symptoms can be either undetectable to the naked eye (i.e., microscopic lesions) or immediately visible (e.g., little raised warts, or papillomas, that often look like cauliflower and may be isolated but are usually clustered). Some people develop relatively minor symptoms months after exposure, requiring same-day in-office excision, cryotherapy, or cautery. Others develop indicators of lesions that could become cancerous without treatment, usually but not always a year or more after exposure, and are referred for a procedure to remove the effected tissue without causing any long-term side effects such as infertility. Some unfortunately develop serious medical complications (usually but not always in combination with avoiding diagnosis and/or medical treatment) years after exposure — including cervical cancer. I happened to develop minor symptoms I dealt with myself, not knowing at the time that I could have received significantly less painful and more effective treatment in a single doctor’s office visit. Those symptoms never returned, but I also developed indicators of lesions that could turn cancerous if neglected. I’m going to go a little more into what that was like before I wrap this post up.
Except for visual confirmation of papillomas, testing for HPV is only available for individuals who have a cervix. It’s done by taking a tiny little wooden spatula and sometimes what looks like a mascara brush, and using it to dislodge and sample cells from the surface of the cervix (i.e., a pap smear), where HPV shows a preference to show up first. A vaginal speculum just holds everything out of the way so the cervix is easier to find and the sample can be extracted. An estimated 80% of sexually active adults at any given time are carriers, and this is largely due to how easily it is spread, even with the use of safer sex barriers. Most people who stigmatize others for their STI status, or even the very notion of having an STI status to speak of (as if being free from any known STI is not a status), either don’t know about HPV because it’s not tested for when blood and urine samples are screened or don’t think that they have been exposed if they don’t have symptoms. This type of thinking only promotes the spread of STIs, because it is rooted in the assumption that if you don’t say anything and don’t show any symptoms, it’s because you don’t have anything.
My Experience With Early Intervention For HPV
My HPV symptoms were detected in multiple consecutive pap smears. From working in a doctor’s office and seeing the reports with my own eyes, I can tell you with confidence that these symptoms are often detected in one or two pap smears and sometimes resolve on their own as the body’s immune system eliminates the virus, but often just don’t develop any further. In a case like mine, the person staining my slides and looking at them under the microscope would be able to see that a recommendation for a more invasive testing was advisable after that second pap smear. My symptoms weren’t going to go away on their own, weren’t just hanging out without bothering any of the adjacent tissue, and appeared to be getting worse. My only support at the time was first a nurse at the sexual and reproductive health clinic, and then a walk-in clinic doctor. I was homeless at the time and attended my appointments alone. That definitely made it more difficult.
The invasive test I needed involved being referred to the women’s clinic attached to a major hospital, where I sat on an examination table with my legs and knees apart, a speculum holding me open, and a light microscope that takes up an entire room pointed squarely at my cervix. With this microscope and a squirt of vinegar (which reacts to infected tissue by turning it white, but not to uninfected tissue, which remains pink), the attending physician determined that the superficial changes detected by my pap smear were starting to move into deeper tissue layers. I had to return three times in total — once for a preliminary examination and biopsy of my cervix, the second time to determine if the particular strain I was presenting with was causing relatively rapid or slow changes compared to the first examination, and the third time for treatment. The biopsy was performed without anaesthetic but was painless. My first two appointments were approximately 3 months apart, and my second two appointments were just a week and a half apart.
The treatment (called a LEEP excision) consisted first of being given multiple shots of local anaesthetic into the head of my cervix. Then a loop-shaped razor literally scooped out the infected tissue with a generous margin of uninfected tissue just to make sure it was all removed in this one procedure. I was also treated with direct application of a coagulant paste and told to rest for the rest of the day. I took the bus when I left the hospital, and only occasionally experienced a moderately severe but relatively quickly passing sensation of tension from deep within my body. This was on the same day as the procedure itself, while I was still on one of the multiple buses on my very long ride home to the other end of the city. I was told I may experience nausea and bleeding, among many other things one would be inclined to expect from what happened in there, but these never came to fruition. I felt better the very next day.
My post-procedure follow-up was a standard pap smear three months later. All the tissue that was removed has since regenerated, and my most recent pap smears indicate that I am still a carrier of HPV. The treatment is considered an early intervention, as by the time it is recommended, the HPV is a couple years shy of turning into actual precursor cervical cancer cells. That is, with regular pap smears (unless both you and your partner were virgins when you first became sexually intimate, and neither of you has been with anyone else), detection of changes in the sample cells is years ahead of the development of even potentially pre-cancerous cells. I received this treatment approximately ten years ago, before the release of the HPV vaccine (roughly five years ago) helped generate and disseminate volumes of accessible information about HPV. Though I am still a known carrier, I have not since been advised to return for invasive testing.
At the time that I was receiving my treatment, it was impossible for anyone but a doctor or nurse to locate information about it, even though all current diagnostic and treatment methods were established by the early 1940s. The nurse responsible for informing me about what the procedure entails did not disclose my HPV status to me — I spotted it by chance on my own chart. As I didn’t know what the words “HPV EFFECT” meant at the time, I didn’t know what to even begin asking about it right then and there. While the doctor was using the microscope to take a look at me, she asked me if I would consent to the hospital residents observing. As a result of saying yes, I have little doubt that I heard a lot more information about what they were all looking at than I otherwise would have. Imagine my surprise a few years later, when I was in college for my medical office diploma and learned for the first time (from my textbook) that the exclusive purpose of a pap smear is to detect changes in cell structure caused by HPV.