When Thou Liest Howling

There are some things we just don’t want to acknowledge aren’t there? Some things that we would rather not hear, not so much because we don’t think they’re important, but because they embarrass us… Or maybe offend us. Sexually transmitted diseases are prime examples.

For some reason, many of us find them difficult to talk about. Admittedly they require rather special venues, and the very subject casts long shadows on the interlocutors no matter how discreetly it is introduced. Rather than appearing as an intimate trust issue, the very fact of its being raised in the first place tends to arouse suspicion -accusations by proxy.

At first, I wondered if this attitude might be a generational thing. I was raised in an era when the most feared unintended consequence of premarital sex (as we called it then), was assumed to be pregnancy; VD -another time-specific term for sexually-acquired disease- was confined to clearly recognizable and therefore potentially avoidable people. This naïveté, of course, didn’t prepare us for the inevitable consequences of our wide-eyed ignorance and even nowadays, those of us still around could yet be dragged, aged and surprised, into the vortex as I outlined in an essay elsewhere:  https://musingsonretirementblog.com/2016/10/16/too-good-to-be-true/

The initial solace of antibiotic treatment also proved too good to be true. Throughout history, sexually transmitted infections were a scourge –the wages of sin as they were considered then. But with the advent of effective treatments, those debts were forgotten –although clearly not forgiven.

Syphilis, gonorrhea, and the more recently characterized chlamydia exacted a terrible toll on fertility and long term health, but until recently, all were fairly amenable to antibiotic therapy –albeit a necessarily changing one. Gonorrhea, however, seems to be particularly adept at developing resistance to the various antibiotics thrown at it.

There are various mechanisms by which a bacterium can become antibiotic-resistant but a common and easily appreciated reason is inadequate initial treatment. Even if an antibiotic is effective, there will usually be some bacteria that are less sensitive to it for whatever reason, and hence require longer antibiotic exposure for it to affect them. People tend to continue treatment only until they feel well –in other words, until the number of bacteria infecting them has fallen below whatever level was required to cause the symptoms. Unfortunately, the few bacteria that remain, are the less sensitive ones that weren’t so easily killed off at the beginning.

Physical barriers to the acquisition of sexually transmitted infections –condoms, for example- are certainly helpful, but men don’t tend to wear them with oral sex, the World Health Organization (WHO) has warned:  http://www.bbc.com/news/health-40520125  This has led to an increasing problem with throat infections according to the BBC News article. ‘Gonorrhoea can infect the genitals, rectum and throat, but it is the last of these that is most concerning health officials.

‘Dr Wi [from the WHO] said antibiotics could lead to bacteria in the back of the throat, including relatives of gonorrhoea, developing resistance. She said: “When you use antibiotics to treat infections like a normal sore throat, this mixes with the Neisseria species in your throat and this results in resistance.” Thrusting gonorrhoea bacteria into this environment through oral sex can lead to super-gonorrhoea.’

The problem is that a throat infection with gonorrhea may be relatively asymptomatic and hence more likely to be inadvertently transmitted to someone else. And ‘It’s hard to say if more people around the world are having more oral sex than they used to, as there isn’t much reliable global data available. Data from the UK and US show it’s very common, and has been for years, including among teenagers.

‘The UK’s first National Survey of Sexual Attitudes and Lifestyles, carried out in 1990-1991, found 69.7% of men and 65.6% of women had given oral sex to, or received it from, a partner of the opposite sex in the previous year. By the time of the second survey during 1999-2001, this had increased to 77.9% for men and 76.8% for women, but hasn’t changed much since.

‘A national survey in the US, meanwhile, has found about two-thirds of 15-24 year olds have ever had oral sex. Dr Mark Lawton from the British Association for Sexual Health and HIV said people with gonorrhoea in the throat would be unlikely to realise it and thus be more likely to pass it on via oral sex.’

And apparently there are only ‘three drug candidates in the entire drug [development] pipeline and no guarantee any will make it out.

‘Prof Richard Stabler, from the London School of Hygiene & Tropical Medicine, said: “Ever since the introduction of penicillin, hailed as a reliable and quick cure, gonorrhoea has developed resistance to all therapeutic antibiotics. In the past 15 years therapy has had to change three times following increasing rates of resistance worldwide. We are now at a point where we are using the drugs of last resort, but there are worrying signs as treatment failure due to resistant strains has been documented.”’

So, we’ve got a potentially untreatable, possibly asymptomatic, and very definitely prevalent infection out there, and a societal reluctance to talk about it… Perhaps it’s time for another approach. Fortunately there is an active search for a gonorrhea vaccine –and a serendipitous observation may have suggested a possible route –although, in retrospect, it seemed an obvious place to start. http://www.bbc.com/news/health-40555702

‘The vaccine, originally developed to stop an outbreak of meningitis B, was given to about a million adolescents in New Zealand between 2004 and 2006. Researchers at the University of Auckland analysed data from sexual health clinics and found gonorrhoea cases had fallen 31% in those vaccinated.

‘The bacterium that causes meningitis, Neisseria meningitidis, is a very close relative of the species that causes gonorrhoea – Neisseria gonorrhoeae. It appears the Men B jab was giving “cross-protection” against gonorrhea.’ This is very early in the work, however, and it seemed only to be effective in a third of those vaccinated. But it is certainly encouraging.

Be that as it may, however, I can’t help but worry that if there is development of an effective vaccine against gonorrhea, it will once again fool us into forgetting about the other diseases potentially transmissible by oral sex, including viruses such as hepatitis, herpes, and HPV (for which, thank god, there is also an effective vaccine), not to mention the bacterially-caused ones like syphilis, chlamydia, and many others that don’t make for salacious headlines.

But I’m not advocating for the formation of a Temperance League to combat a practice that is likely as old as humanity, nor do I have any religious or ideological objections to its persistence in our society, but I do believe that the Past informs the Future. I think that it would be prudent to ensure that all participants –newcomers to the field, as well as those who have already passed through and are merely nibbling at memories- have a working knowledge of those risks that should not be placed, as Shakespeare put it, on the windy side of care

I just wonder if those who are entrusted with sexual education nowadays would put it so beautifully.
















Teenage Sexuality

It seems like every time I turn around nowadays, I learn something new about what my colleagues are doing -or not… A recent article published online in JAMA Pediatrics, Dec. 30/13 (abstract: http://archpedi.jamanetwork.com/article.aspx?articleid=1791584 ) suggests that we in the medical profession are not doing enough to disseminate information about sexual health -especially to teenagers. The study was from the USA (North Carolina), and so might not be universally applicable, but it got me thinking.

I suspect the problem is not confined to the study area reported; it is all too probable -if not understandable- in most countries, but Canada is the one with which I have the most experience, so let me begin with it. Teenagers in any country, are a difficult group: they are usually healthy and often unaccustomed to visiting a doctor except with a specific complaint to be resolved. The age difference between a teen and her doctor, or nurse, is usually significant and often an impediment to easy and trustful communication. And sometimes her world-view and experience clouds the risk and her own consequence-assessment of her behaviour -especially if others are engaging in it. Many have yet to learn from their mistakes…

Another not insignificant factor -at least in this country- is the frequent accompaniment into the doctor’s office of the teen by her mother. A totally understandable and laudable practice, at least a priori.  Sometimes it is to give the young girl confidence on her first visit, or to make sure that she asks the right questions and of course receives the correct answers. But it does make it difficult to delve more than superficially into the sexual history, contraceptive needs, and more particularly, issues surrounding normal, healthy sexual functioning: such things as pain, lubrication, orgasm or even partner expectations. There are a lot of questions that are both embarrassing and difficult for her to raise, let alone answer, with a parent present. A mother can be a two-edged sword…

And I suppose that one of the cardinal rules of medicine –Listen first, talk later– is also turned on its head with teen sexuality: teens seldom ask about it, in my experience. They’ll ask about contraception (sometimes) or sexually transmitted diseases -and more specifically whether or not I think they have one- but almost never about other sexually related concerns unless I ask them. Whether it’s because I am a male and generationally distant, or because they are too embarrassed to raise the subject -especially when the answers so obviously lie just a mouse-click away- I’m not sure. But I can say that when I do raise the subject, after a short, suspicious period of feigned indifference, most seem relieved.

As a male gynaecologist dealing with often nervous, and bashful teenage girls, the problem is usually finding a way to work into the subject of sexual health without alarming or further embarrassing the patient -the younger ones in particular. Indeed, wherever possible I try to have them seen by my female associates instead, recognizing that they may feel more comfortable dealing with another woman. No doubt this could be seen as an abdication of my responsibility to a patient in need of care, but in many cases it’s a more sensitive approach, and one that may ultimately prove more valuable and helpful to the teen at a particularly impressionable -not to mention vulnerable- stage of her life.

But in reality, and given the exigencies and problems inherent in finding available specialists, I realize that sometimes we -the patient and I- must attempt to transcend both the gender and the generational gap as best we can. And so, with regard to inquiries about sexual health, I try to fall back on experience and advice from my more seasoned colleagues. It’s usually inappropriate to inquire without a reason -it smacks too much of prurient curiosity even from a health professional. But sometimes it can be a careful addendum to questions about contraception. Or perhaps during the queries about some other problem for which they have sought help -pain, for example. I am often asked to see a young patient discovered to have an ovarian cyst (a not uncommon, but often painful result of irregular or absent ovulation in younger teenagers -benign, but nonetheless frightening). The discussion lends itself to asking if she gets pain with such things as exercise, bowel movements… or intercourse -a natural progression of embarrassing yet understandably relevant questions that allows further pursuit of the topic. A rather different approach is to embed the sexual questions in the lengthy and detailed initial history that allows the girl to see that you are being thorough -not intrusive. It is unabashed subterfuge, I admit, but in many such circumstances, the end does justify those means. Or is it just me?

So I can understand why it may seem that the sexual health inquiry appears to be absent or minimal -in the study at mentioned at the beginning, at any rate.  One must first achieve rapport -a relationship deemed to be both trustworthy and private- and this takes time; it seldom occurs on the first visit, and almost never with the mother present. It is a long-term goal and cannot be hurried. Even those admittedly tentative answers to the thorough and hopefully sensitive consultation history may need to be reconsidered -re-approached as it were- once she has come to know and trust you.

I think all of us in the position of health care advisers wrestle with these challenges and recognize that our goal in promoting teen sexual health should be to interfere less and to educate more; to facilitate her ability to make informed choices; to help her to recognize and avoid risks; and perhaps most important of all, to be sensitive to her growing independence and to let her understand that we celebrate it. Criticism will only turn her away. 

But we are all learning; communication between age groups and genders is often riven with inadvertent blunders and unplanned insensitivity. Words -questions- can be met with sullen withdrawal or sudden suspicion and mistrust. Anger. Rejection. Embarrassed silence… It was Oscar Wilde who said: Experience is the name every one gives to their mistakes. And yet we must never forget that experience teaches -even across generations. Rapport is not often given freely, it must be won, and its path frequently winds through a dark, mysterious forest of little mistakes.