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.

 

 

 

 

 

 

 

 

 

 

 

 

http://www.bbc.com/news/health-40555702

 

 

Advertisements

PTSD in Gynaecology?

Post Traumatic Stress Disorder (or PTSD) is an anxiety disorder caused by being exposed to a traumatic or frightening event. It has been described in various guises since antiquity: http://www.bbc.com/news/health-30957719, but although we have traditionally ascribed it to military veterans, it is by no means confined to those who have been in the midst of battle. Paramedics, police officers, and various other sorts of first-responders are also exposed to frightening and traumatic events. The DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) has even allowed a variant for those emergency workers even if they are only exposed to disturbing videos in the conduct of their jobs.

So I suppose it should not come as too much of a surprise that someone would take the leap and wonder whether the public, exposed as we all are to social media, would be at risk as well: http://www.bps.org.uk/news/viewing-violent-news-social-media-can-cause-trauma   There followed the usual offence at what seemed like an attempt to demean the diagnosis of PTSD in those felt more worthy of its acquisition, and in conditions far more important and deserving, but nonetheless there is a spectrum of manifestation inherent in most diagnoses.

The BBC posted a helpful primer on PTSD http://www.bbc.com/news/health-26867615 but in brief, the diagnosis requires: flashbacks to the event, avoidance behavior, sleep disturbance, and mood changes.

I have to say I was skeptical that we should even consider that anything found on social media could have such an important impact that could in any way be considered PTSD –however attenuated. It seemed almost an insult, a belittling of those who had undergone real trauma. Until, that is, I remembered Lucille.

She was a young lady visiting from another province who had been sent to me for a second opinion from the emergency department at the hospital across the street. Her problem was abdominal pain –chronic and unexplainable pain in the pelvic region, for which she had been thoroughly investigated elsewhere with ultrasounds, CT scans, an MRI and even –no doubt in desperation- a laparoscopy four or five years ago to view the area more directly. And all, said the accompanying note, were normal.

She was not what I was expecting; rather than an anxious woman sitting quietly in the waiting room with her face locked in pain, instead I found a smiling, smartly dressed young lady happily talking to the pregnant woman in the seat beside her. She smiled when I walked over and immediately extended her hand for me to shake.

“I’m so happy you could see me on such short notice,” she said as I led her down the corridor to my office. And she did indeed seem cheerful and, well, normal as she seated herself across from my desk by the window. “What a wonderful view of the ocean from here,” she almost purred, staring past the buildings and traffic at the almost-invisible water far in the distance. “Vancouver is such a wonderful city…”

I sensed her cheer was other than completely genuine, as her words wound down and slowed. Sometimes, with chronic conditions like pain, I like to wait until the patient is ready to speak -unprovoked, as it were. Unencumbered by a line of questioning known all too well to her that leads… nowhere. She was silent for a while as she turned her attention to the office itself, her eyes alighting like sparrows first on a painting on the wall, then on a wooden carving from Ethiopia I had placed on the desk so it looked out between the leaves of a plant. They stopped no place for long, revisiting their favoured twigs almost at random.

“Offices are all different, aren’t they?” I said, to begin the conversation.

She nodded thoughtfully. “I suspect they reveal a lot about the doctors…”

“And the patients who notice.” It provoked another smile.

Her face became serious –a major change. “Look, I don’t want to waste your time, doctor. I’m certainly grateful you could see me, but maybe I should wait until I get back to Ontario to get it checked out.”

“It..?” She looked down at her lap, as if the little sparrows were tired of flitting about. “The note from the ER said you were having some pain… Care to tell me a bit about it?”

She still seemed reluctant to look up. “Oh, I get these pains every now and then. No big deal, though.”

She risked a glance and I immediately seized the opportunity. “Well, suppose I just take a brief history and then if you feel you want to wait till you get back to Ontario, I can fill your doctor in as to what happened while you were here in paradise.”

She nodded her assent and for the first time, her eyes didn’t flee from my face. Was it hope? Or merely resignation that it was beginning again?

We all expect that we will be able to find the treasure where nobody has succeeded before, but the only thing I could discover in her history that might be remotely related to her pain was an episode of Chlamydia –a sexually transmitted condition- several years before. It had been treated and subsequent cultures had demonstrated cure. “When did the pain start?” I asked, almost as an afterthought, but I think she could see through my strategy.

The memory seemed uncomfortable to her, and she looked out the window again.

After an awkward moment of fidgetting silence, I said, “Sexual diseases are always difficult to talk about, I think…”

“My friend didn’t think so,” she suddenly blurted out before I could even finish my poorly worded attempt to console her. “She got an STI and had to be hospitalized when it spread through her abdomen… They even had to operate to remove the pus. She sent me a picture of her tubes they took during the operation…” She looked as if she were about to cry, but grabbed a tissue from the desk and dabbed her eyes to recover. She lapsed into a morose silence and turned her head so she could see the door.

“You know, I’d been fond of the guy who gave it to me; I’d gone out with him for a couple of years… And yes we used condoms!” She stabbed me with a sudden glare and turned her head away again. “I did everything right, but I still got it.” She sighed heavily and stared at her lap again. “I mean, how do I know I don’t still have it -but without symptoms? Or that I haven’t gotten it again from somebody?” Her hands were nervously clasping and unclasping. “They did a laparoscopy shortly after the infection and it was normal, but that was years ago…”

The time for my questions was over; I let her talk.

“I read that PID [pelvic inflammatory disease] can be silent after an infection and the damage can be going on even without symptoms…” She considered that for a second or two. “I suppose I twisted my doctor’s arm to do the laparoscopy. But anyway, she didn’t find anything. Nothing abnormal.” Another sigh. But my girlfriend kept warning me about it, so of course I read as much about it as I could online. I even looked at videos of operations for PID…” Her eyes teared up immediately. “I couldn’t stop looking at them,” she managed to whisper between sobs. “They were terrible! Frightening: great slimy fat tubes stuck to bowels and everything… And in some of the videos, when they tried to dissect them, there was blood everywhere! And pus oozing out of dark little spaces the tubes had walled off…” She considered the implications of what she’d said and closed her eyes briefly. Hid behind her face. “I’ve hardly had sex since that Email and I’m never going to trust anybody again,” she blurted out abruptly with her fists clenched. “I mean I keep thinking about those videos; I wake up in the middle of the night, and there they are, running through my mind!”

She stared at my face for a second. “You think I’m stupid for watching all those videos, don’t you?” she yelled at me. “But I couldn’t help it! I just knew that it was going on inside of me: big fat greasy sausages filled with sticky white ooze..!” And then, just as suddenly she stood up and pinned me to the wall with venomed eyes. “You’re the same as all the rest, you know. And I know you don’t believe me!”

She turned and walked to the door. “And don’t bother sending anything to my doctor in Ontario, either. I’m gonna find another one.”

She disappeared through the door leaving me wondering how I could have handled things differently. But in a moment a head poked around the door again –but only briefly. Awkwardly. “I’m sorry doctor… You’re really great! Honestly.” And then it disappeared into whatever hellish world it was forced to inhabit.

Did she have PTSD? A variation of it somewhere on the spectrum? Or was she just embarrassed that she’d disclosed so much to a stranger? I suppose I’ll never know, but I hope that somebody, somewhere, takes her seriously. She, just like anybody else with PTSD has a life to live. Deserves to live.