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

 

 

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Violence Against Women

According to a recent meta-analysis by the World Health Organization, one in three women worldwide are subject to intimate partner violence (IPV) http://www.sciencemag.org/content/340/6140/1527.short . And it’s not just a third world problem either, as we Canadians with our often parochial outlook would no doubt like to believe. True, some countries seem to be over-represented: ‘East Asia having the lowest incidence, at 16.30% (range, 8.9% – 23.7%), and Central Sub-Saharan Africa having the highest incidence, at 65.64% (range, 53.6% – 77.71)’, but we in Canada are certainly not immune. http://www.huffingtonpost.ca/kirsty-duncan-/harper-womens-rights_b_4435285.html

Recognizing this, there has been a move to screen women for IPV in hopes of decreasing the violence or improving the outcomes for the victims. However, in a review published in the May 13 edition of the British Medical Journal, the lead author, Dr. Lorna O’Doherty from the University of Melbourne ‘Did not detect a decrease in rates of violence in women’s lives as a result of screening nor did it find improved mental and physical health outcomes for women.’ http://bit.ly/1m6Vskr

I have to admit that I had hoped that screening would have had more of an effect than is reported, but maybe on closer examination there are readily identifiable reasons for this. The whole issue seems to involve a complex algorithm with a lot of contextual conditions that have to be considered. First of all, the woman may not yet be ready to admit abuse is taking place; she may not actually see it as ‘abuse’ and so is unlikely to report it as such, even if asked. Or, perhaps she has thought about it, but isn’t yet ready to address or admit the issue –especially to others because of the stigma. There are phases through which she needs to progress in accepting and addressing the abuse. And yet, even if she is ready, her ability to admit it to someone else is going to be predicated on several factors -the WHO report again (and I quote an article in Medscape for the summary):

The report points out that certain healthcare settings (eg, antenatal clinics and HIV screening clinics) offer good opportunities to spot problems and intervene.

However, to be effective in such situations, the recommendations say, certain minimum standards need to be in place. Those include that:

  • providers need to be trained on how to ask about violence,
  • standard operating procedures need to be in place,
  • consultations need to take place in private settings,
  • confidentiality needs to be guaranteed,
  • referral arrangements need to established and maintained, and
  • providers need to be properly equipped to handle the physical and mental consequences of sexual assault.

This sounds reasonable; our obstetrical delivery unit provides universal IPV screening, but I am disappointed with the finding in that study published in the British Medical Journal that even so, the mental and physical outcomes for those women were not improved. And although we are probably missing the vast majority of women who suffer from abuse (and in some cases men as well -but more likely detected in a different venue), one would still like to hope that for those we have found, discovering the problem would be a step towards its solution.

But I think that public recognition of the problem is an equally important, if preliminary step. I sometimes wonder if we inadvertently stigmatize IPV because we, as a society, simply do not acknowledge it. It is something we’d rather not think about, or if we do, we do so judgementally. So, despite various professionals attempting to detect it and thereby (it was hoped) ameliorate the consequences, the victims remain reluctant to admit it is even happening. They, like the rest of us, see it as shameful and perhaps reflecting on their own choices, their own self-worth…

I’m reminded of our Canadian disgrace: the seeming indifference to the disappearance and violence against our Aboriginal women. There is, of course, lip service acknowledgement by the government that there might be a problem, but a rather indignant assurance that they are taking steps to resolve the issue seems to be all they have to offer. One could be forgiven for wondering whether they simply didn’t want any more public attention drawn to the problem.  http://www.huffingtonpost.ca/2013/09/19/canada-un-aboriginal-women_n_3952425.html

I see the problem of violence against women differently. I think that the more it is publicized, the more it will be recognized, and the more will be society’s demand that the hitherto secret norm of violence will be seen to be inappropriate –no, not inappropriate, wrong. Think of the changing (I’d like to say changed but I suspect it would be premature) attitude to drinking and driving. As a society, we are realizing it is something to be condemned, not tolerated. Something that can be, and should be, discussed in the open. Something that is no longer acceptable…

It is possible to alter behaviour we have always viewed as undesirable, yet secretly condoned by our unwillingness to confront it. We need to acknowledge and tackle it as a society –and we need confront it often, publically, rationally, doggedly. I am reminded of something Lucretius wrote: The drops of rain make a hole in the stone, not by violence, but by oft falling.