The Other Epidemic
Dr. Tim Schacker had a double dose of bad news to deliver. The 30-something gay man sitting in his office was part of a study on new HIV infections, and Schacker, then a researcher at the University of Washington in Seattle, had to tell him that he'd contracted both herpes and HIV in a single sexual encounter. As if unsurprised, the patient took the news about HIV almost in stride. The herpes diagnosis, however, sent him nearly over the edge.
"In my work," says Schacker, currently a professor of medicine at the University of Minnesota, "that's a relatively common phenomenon. People get distraught over the fact they have herpes, not HIV."
Schacker's story illustrates not only the stigma that surrounds herpes and the fatalism that some gay men have adopted when it comes to getting HIV, it also indicates the widespread lack of basic information that exists among Americans regarding sexually transmitted diseases. While HIV education and prevention efforts have spread the word about the virus that leads to AIDS, information about other, less-deadly STDs has generally received little notice in the mainstream media or the nation's classrooms. Even among the supposed heirs of the "sexual liberation" movement--gay men, lesbians, bisexuals, and transgender individuals--understanding of sexual-health issues is often spotty.
"My experience is that people are less well educated about other STDs than they are about HIV," says Dr. Leslie Baken, a physician with Park-Nicollet Clinic in St. Louis Park. "There's a lot of data that supports the notion that the majority of people can't even name an STD other than HIV."
An estimated 10 to 12 million new STD infections are reported in the United States each year. In 1996, growing concern about the spread of STDs prompted the Institutes of Medicine to issue a 1996 report titled "The Hidden Epidemic," which concluded that no "effective national system" for STD prevention existed in the United States. Earlier this year, the Centers for Disease Control launched a far-reaching campaign to curb STDs.
Within Minnesota, statistics on STDs tell a similar story. Health-care providers across the state are required to report cases of four types of STDs--syphilis, gonorrhea, chlamydia, and chancroid (which is rarely found here)--to the Minnesota Department of Health (MDH). Additionally, state officials collect data on hepatitis B, HIV, and AIDS--all of which are often, but not exclusively, sexually transmitted.
Overall, new cases of the four reportable STDs in Minnesota have decreased slightly in recent years. In 1997, there were 9,329 new infections reported to MDH, down from the 10,692 new infections reported in 1994, but up from 8,162 new infections in 1996. New cases of syphilis dropped 76 percent from 1992 to 1996, according to MDH figures, and reports of gonorrhea have dropped substantially since their most recent peak four years ago. Chlamydia rates, which have skyrocketed in the United States in recent years, increased from 117 cases per 100,000 individuals in 1996 to 145 cases per 100,000 persons in 1997.
But no matter what one makes of the numbers, the rates for sexually transmitted diseases still dwarf the rates for other types of infection: "In our clinic setting," says Baken, "STDs are the most common cause of infection." Baken's clinic saw 168 new cases of STDs in 1997, compared to 120 cases of the giardia, a common bacterial infection, and 30 cases of HIV.
Public-health experts also have other reasons to remain concerned about STDs in Minnesota: The state's reporting requirements don't extend to such STDs as herpes, genital warts (caused by human papilloma virus or HPV), or hepatitis A and C. A careful assessment may ultimately show that the cost of monitoring such STDs outweighs any health risks or treatment costs, says Bob Tracy, public policy director at the Minnesota AIDS Project, but currently there's insufficient data to make such a determination.
"We need to do some prevalence studies on these other STDs," Tracy says. "What are the characteristics of people who contract these STDs?" Although MDH categorizes its STD reports according to gender, age, geographical region, and race, there's no breakdown of the data by "risk factors," which are behaviors that might suggest the mode of transmission. Collection of HIV data, for example, takes into account such risk factors as IV-drug use and types of sexual behavior.
Quantifying the impact and prevalence of STDs within Minnesota's queer community is nearly impossible. MDH doesn't consider "sexual orientation" in collecting data on STDs. But Schacker points out that a recent study in Seattle found that cases of gonorrhea were on the rise in young gay men. Anecdotal evidence relayed by local physicians who treat gay men seems to indicate a similar trend in the Twin Cities, he says. If reports of a rise in unsafe sex among homosexual men nationally are true, he adds, there's likely to be a corresponding jump in local STD reports.
MAP's Tracy says that the STD epidemic is of particular concern, not only to gay men, but to other queers as well: "If HIV went away today," Tracy says, "it's my assumption that we'd still have a serious health crisis--particularly among gay men, but also within the GLBT community as a whole."
But while HIV/AIDS information campaigns have dominated the public-health world for nearly two decades and often have been specifically tailored to reach the GLBT community, little effort has been made to educate queers about the hazards of other STDs. Although some STDs are invisible to the naked eye, most of them can have considerable effect on transmission of HIV, fertility in women, or general sexual health.
The links between HIV and other STDs have long been clear, according to Schacker. In the late '80s, for example, as gay men began to respond to safe-sex campaigns, CDC studies showed that rates of gonorrhea declined among men who have sex with men. An article published in the New England Journal of Medicine last year indicated that in a study of women with HIV, 50 percent had contracted HPV or another STD. The link is twofold, Schacker says: On the one hand, it's a matter of behavior. A person engaging in sex with multiple partners increases their risk of contracting HIV or another STD with each new partner. Additionally it's a physical problem: Sores and lesions caused by STDs can create a gateway into the body that facilitates HIV transmission.
STDs can also impact child-bearing--a particular concern to lesbians considering giving birth. Chlamydia is the leading cause of female infertility and female genital tract infections. For child-bearing women with chlamydia, the most commonly reported STD in Minnesota, there's a 60 to 70 percent chance that they'll transmit the STD to their unborn infants.
STDs may also be related to other health problems in lesbians, says Dr. Jeanne Marrazzo, a University of Washington researcher who, a few years ago, organized a pilot study of 150 women who have sex with women. Marrazzo found that 30 percent tested positive for HPV, the virus responsible for the majority of cervical cancers. She scoffs at the suggestion that lesbians don't get STDs, noting that such a statement presumes that the women have never had sex with a man and that they don't engage in risky behaviors during lesbian sex. "It's a combination of homophobia and sexism," Marrazzo says. "People believe you can't have sex if there's not a penis involved. If there's no penis, they say, it's not really sex."
Queer youth are also believed to be at high risk for STD infection. A Minnesota Student Survey conducted in 1995 found that one in five teens in the state reported having an STD.
This month, the Minnesota Department of Health launches an expanded initiative on STD research and testing with a $300,000 appropriation from the Minnesota Legislature. The one-time funding, approved by lawmakers this spring, will be used to conduct a statewide assessment of the need for STD prevention services and to conduct research on the prevalence of STDs within particular populations. Fifty thousand dollars of that amount will be used to conduct free STD screenings at health-care clinics.
Boosting STD research, prevention programs, and education across the state is not only important in and of itself, according to Tracy, it may also help spread the word about HIV in greater Minnesota. Many small-town doctors, for example, see HIV as an urban issue and, therefore, irrelevant to their practices. "But rural physicians will show up for a training on STDs," Tracy says. "By getting them in the doors to talk about STDs, it's a natural extension to talk about HIV."
The same logic applies when it comes to STD/HIV prevention among young people. "Young people may not see HIV as an immediate risk," Tracy says. "But if you're dealing with STD prevention, you're contributing to HIV prevention."
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