There is one fact driving the creation of this monograph -one fact that makes the question of condom effectiveness an urgent one. We are facing an epidemic of sexually transmitted diseases.
An epidemic is defined as a problem “occurring suddenly in numbers clearly in excess of normal expectancy, said especially of infectious diseases but applied to any disease, injury, or other health related event occurring in such outbreaks.” The United States is experiencing an epidemic of sexually transmitted diseases. The number of people in this country infected with diseases is far in excess of normal expectations and much higher than just a few decades ago.
In the 1960’s there were two STDs of major concern -syphilis and gonorrhea -both curable with penicillin. There has been a change in the nature of the STD problem.
Today, according to the Institute of Medicine, there are more than 25 STDs, many of which are viral with no cure. It is estimated that over 15 million new sexually transmitted infections occur every year in the United States. One-fourth of these new infections occur in teens, and two-thirds occur in individuals less than 25 years of age.
There are approximately 70 million current STD infections in the United States. The most common of these is genital herpes, which alone infects over 20 percent of Americans age 12 or older. A recent study reported that an estimated 7.9 percent of 18 to 35 year-old residents of Baltimore, MD, have untreated gonorrhea or chlamydia infections, or both. Another large study showed that 50 percent of sexually active women ages 18-22 were infected with human papillomavirus, the virus that causes over 93 percent of cervical cancer.
WHY IS THERE AN STD EPIDEMIC?
The STD epidemic is a result of individuals having, on average, more sexual partners in their lifetime and having sex with partners who engage in more risky behaviors than they did a few decades ago. This is important because an individual’s lifetime number of sexual partners is one of the most important -if not the most important -risk factors for contracting an STD. Furthermore, the average number of sexual partners among members of a population is a very important factor in determining the rate of disease spread -the more partners people have, the more rapidly an STD spreads through the population. The younger an individual is when he or she begins sexual activity, the more partners they tend to have. This is especially troubling because adolescent females are more susceptible to some STDs than are adult women.
Sexually transmitted diseases are no longer confined to one age group or area of the country -these diseases are everywhere. While particularly common in teens and young adults, STDs -including HIV/AIDS -have become more common even in adults over 50. Sexually transmitted diseases occur among people with different educational backgrounds, in every income bracket, among members of all races and in both genders. But females carry a disproportionate burden of negative consequences from STDs. For some STDs, a female who is exposed to an infected sexual partner is more likely to become infected, and once infected, females experience more health-compromising disease complications. Sexually transmitted diseases discriminate against females -they are sexist.
STDs AND THEIR IMPACT ON INDIVIDUALS
Contracting an STD can have life-altering consequences. Some people die. Most don’t-but many live with consequences that change their lives forever. Here we discuss the effects of the most common STDs.
Chlamydia infects up to 5 to 10 percent of sexually active adolescents. It is the most common non-viral STD. Up to 85 percent of infected women have no symptoms. In approximately 20 to 40 percent of women who are untreated, the infection will progress into their upper genital tract and can damage their fallopian tubes, causing infertility and ectopic pregnancies. Up to one-third of in vitro fertilization (IVF) treatment cycles where the woman is infertile, are necessary because of past STD infection (usually chlamydia and occasionally gonorrhea). Chlamydia and gonorrhea both can cause pelvic inflammatory disease which can damage a woman’s fallopian tubes.
Human papillomavirus (HPV) is the most common viral STD. A recent major study that included sexually active 18-to-22 year old women found that 50 percent were infected with HPV. Approximately 1 percent of these women will experience genital warts and 14 percent will experience cervical abnormalities. Genital warts can be very difficult to eradicate.
HPV is the cause of almost all cervical dysplasia (precancerous change of the cervix) and of 93 percent of all cervical cancer. An estimated 4800 deaths were caused by cervical cancer in the United States in 1999, as compared to an estimated 4,063 female deaths due to AIDS that same year.
Genital herpes infects 20 percent of Americans age 12 and older, and specifically for African Americans, that figure jumps to 45.9 percent. Additionally, from 1976 to 1994, there was an increase of over 450 percent in genital herpes among white adolescents. Once an individual is infected with herpes, he or she is infected for life. There is no cure. Herpes outbreaks can occur at very inconvenient and upsetting times – under stress, at the time of anticipated intercourse, and during the delivery of a baby (which occasionally causes the newborn to be infected if delivery is vaginal). Also, an individual with genital herpes faces an increased risk of becoming infected with human immunodeficiency virus (HIV) from a sexual partner who is infected with HIV.
HIV/AIDS has caused the deaths of almost 500,000 Americans since the epidemic began. AIDS has no cure and while many HIV-infected people are living longer with modern drug therapy, it is still considered a fatal disease. Most people who are HIV-infected will die of AIDS unless they die of some other cause first. There is no cure or vaccine on the immediate horizon. The possibility of transmitting a fatal disease to a sexual partner should make any HIV-infected individual seriously consider whether or not he or she should be involved in any sexual activity that would put a partner at risk.
It is estimated that approximately 78,000 individuals are newly infected with Hepatitis B in the United States each year. It is also estimated that there are between one million and 1.25 million carriers of Hepatitis B. This occurs because from 2 to 10 percent of individuals with a new Hepatitis B infection are not able to rid themselves of the acute infection. These persons with what is then called “chronic Hepatitis B” usually have no symptoms until they develop liver problems, problems that are very common in this group. Fifteen to 25 percent may die prematurely from either cirrhosis or liver cancer. Approximately 5,000 Americans die annually from these conditions.
Individuals who are chronic carriers of Hepatitis B can transmit the disease through sexual contact or bodily fluids. Approximately 50 percent of new Hepatitis B infections result from sexual contact.
An estimated four million individuals in the United States are currently infected with Hepatitis C. Approximately 20 percent of Hepatitis C is sexually transmitted. (Oddly, in long-term monogamous couples in which one partner is infected with Hepatitis C this does not usually happen. It most often occurs when an individual has had multiple partners.)
Hepatitis C infection is the most common cause of liver cancer in the United States. It also causes chronic hepatitis. Hepatitis C causes the deaths of 8,000 to 10,000 Americans per year.
Trichomoniasis vaginal infections are caused by a protozoan parasite. This parasite has a tail and moves very much like the human sperm does. It has been found in as few as 3 percent of college students attending a student health clinic and as many as 37 percent of women working in the sex industry. In their book, Infection Protocols for Obstetrics and Gynecology, Drs. Mead and Hager make the statement, “Since the primary and only significant mode of transmission is sexual intercourse, increased risk of infection is associated with increased numbers of new, different, or casual sex partners. Therefore, whenever trichomoniasis is diagnosed, the patient should be evaluated for other sexually transmitted diseases, such as gonorrhea, syphilis, chlamydial infection, and HIV infection. It is also possible for trichomoniasis to be associated with bacterial vaginosis or monilial infection, or both, in a combined vaginitis.”
Lest the mention of HIV by Drs. Mead and Hager go unnoticed, it is important to understand that trichomoniasis does seem to increase the risk of a person becoming HIV-infected, if, after becoming infected with trichomoniasis, they have sexual intercourse with someone who has HIV infection. As pointed out by Royce et al, “Gonorrhea and chlamydia and trichomoniasis infection are associated with a relative increase of 60 to 340 percent in the prevalence of HIV infection in men and women.”