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353 Chapter 13 Sexual Problems and Dysfunctions Learning Objectives Prevalence and Types of Sexual Problems and Dysfunctions LO 13.1 Describe the prevalence and types of common sexual problems and dysfunctions. Origins of Sexual Problems and Dysfunctions LO 13.2 Discuss biological factors in the development of sexual problems and dysfunctions. LO 13.3 Discuss psychosocial factors in the development of sexual problems and dysfunctions. Solutions for Sexual Problems and Dysfunctions LO 13.4 Describe the PLISSIT and Masters and Johnson approaches to addressing sexual problems and dysfunctions. LO 13.5 Outline the treatment of specific sexual problems and dysfunctions. JackF/Fotolia
354 Chapter 13 Many (if not most) people experience some type of sexual problem from time to time. Many men occasionally have difficulty getting and keeping erections, or ejaculate more quickly than they or their partners would like. Some women notice that their desire for sexual activity is sometimes lower than they’d like it to be, or that they occasionally have difficulty becoming sexually aroused or reaching orgasm. Temporary or occa- sional problems with sexual response, as concerning and troublesome as they often are, do not necessarily qualify as clinically defined sexual dysfunctions. Only if a sexual problem persists over time and causes the person distress does it qualify as a sexual dysfunction. Sexual dysfunction is a persistent or recurring lack of sexual desire or difficulty becoming sexually aroused or reaching orgasm. People who do have sexual dysfunc- tions may avoid opportunities for sexual interaction with partners. They may anticipate that sex will result in frustration or physical pain, rather than pleasure and gratification. Because of the emphasis our culture places on sexual competence, people with sexual dysfunctions may feel inadequate or incompetent, which diminishes their self-esteem. They may experience guilt, shame, frustration, depression, and anxiety. Many people with sexual problems or dysfunctions find them difficult to talk about with their partners and health care professionals. A woman who can’t have an orgasm may be reluctant to mention it to her doctor, and a man who has periodic difficulty getting an erection may never bring up the topic during his annual physical. Patient embarrassment about bringing up sexual concerns is often compounded by physicians who may never ask about them. Prevalence and Types of Sexual Problems and Dysfunctions LO 13.1 Describe the prevalence and types of common sexual problems and dysfunctions. Because many people are reluctant to reveal their problems with sexual functioning to researchers, we don’t have precise figures on their prevalence. Furthermore, studies measuring their prevalence have used different measures and sampling techniques and have yielded different results. Some surveys have asked respondents general questions, or just a single question, about their experience of sexual problems, while other studies have involved having respondents complete detailed scales to measure the occurrence of specific sexual dysfunctions. Although there is some variation in the figures gleaned from this body of research, we can make several generalizations: sexual dysfunction A persistent or recurrent difficulty with a lack of sexual desire or arousal, or difficulty reaching orgasm. TRUTH OR FICTION? Which of the following statements are the truth, and which are fiction? Look for the Truth-or-Fiction items throughout the chapter to find the answers. 1 Sexual problems are rare. T / F ? 2 The most common cause of painful intercourse in women is vaginal infection. T / F ? 3 Sex therapy teaches a man with erectile disorder how to “will” an erection. T / F ? 4 Many sex therapists recommend masturbation as the treatment for women who have never been able to reach orgasm. T / F ? 5 A man can prevent ejaculation by squeezing his penis when he feels that he is about to ejaculate. T / F ?
Sexual Problems and Dysfunctions 355 • Females are more likely than males to report having sexual problems. • The occurrence of nearly every kind of sexual problem increases with age, with premature (early) ejaculation being the exception. • The most common sexual problems in women are related to a lack of interest in sex. • The least common sexual problem, at least for males, is sexual pain. • Despite the stereotype that males are “always ready” for sex, a sizable proportion of males actually report having little interest in sex. As shown in Table 13.1, a recent Canadian study shed light on the prevalence of sexual problems in a sample of mid-life adults. The results suggest that sexual prob- lems are common among adult Canadians, and the study found that the occurrence of these problems affected people’s level of happiness with the sexual part of their lives (Quinn-Nilas, Milhausen, McKay, & Holzapfel, in press). 1 ❯ T / F Truth or Fiction Revisited Fiction. Sexual problems are common. Nearly half of women and at least one third of men will report having a sexual problem at one time or another. Although most studies investigating the prevalence of problems with sexual func- tioning have focused on adults, recent research has found that many young people also experience sexual problems. For example, a study of young people in France found that although most reported that they had a satisfying sexual life, sexual problems were not uncommon (see Table 13.2). Lucia O’Sullivan from the University of New Brunswick and colleagues investigated the occurrence of sexual problems among a Males Yes “My interest in sex is lower than I would like it to be.” 29.6% “I have trouble getting and maintaining an erection.” 23.8% “I ejaculate more quickly than I would like.” 24.7% Females Yes “My interest in sex is lower than I would like it to be.” 39.6% “I am not able to have an orgasm.” 13.3% “I experience pain in the vaginal area during sex.” 17.1% SOURCE: Based on Quinn-Nilas, Milhausen, McKay, & Holzapfel. (2018). Prevalence and predictors of sexual problems among midlife Canadian adults: Results from a national survey. The Journal of Sexual Medicine, 15(6), 873–879. Elseveir. Table 13.1 Prevalence of Sexual Problems Among Canadian Males and Females 40 to 59 Years of Age Thinking back over the last six months, have you experienced any of the following problems on a regular basis? Males Often/Sometimes Lack of sexual desire 10% Erection problems 5% Premature ejaculation 20% Females Lack of sexual desire 24% Difficulty reaching orgasm 28% Pain during intercourse 22% SOURCE: Moreau, Based on Moreau, C., Kagesten, A. E., & Wn Blum, R. (2016). Sexual dysfunction among youth: An overlooked sexual health concern. BMC Public Health, 16, 1170. Table 13.2 Prevalence of Sexual Difficulties Among Sexually Active Males and Females 15 to 24 Years of Age: France
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356 Chapter 13 sample of Canadian youth aged 16 to 21 over a two-year period and found that 79% of males and 84% of females reported a problem with sexual functioning over the course of the study (O’Sullivan, Byers, Brotto, Majerovich, & Fletcher, 2016). Unfortunately, many Canadians who experience problems with sexual functioning don’t seek help. In a study by Brock, Moreira, Glasser, and Gingell (2006), 75% of those with sexual function difficulties hadn’t sought help from health professionals. Types of Sexual Dysfunction The most widely used system of classification for sexual dysfunction is based on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disor- ders (DSM). In 2013, a new edition of the DSM, referred to as the DSM-5 , was released (American Psychiatric Association, 2013a). Compared to the previous edition, which was published in 2000, the new DSM-5 made several important changes in the way sexual dysfunctions are classified (IsHak & Tobia, 2013). Among the most important changes were that what was previously called “female hypoactive desire disorder” and “female arousal disorder” were merged into a single disorder called “female sexual interest/arousal disorder.” This change was made because, for many women, the desire and arousal phases of sexual response often overlap (Brotto, 2010; Gra- ham, 2010). Another significant change that was made in the DSM-5 was that the female sexual pain dysfunctions, “dyspareunia” and “vaginismus,” which also often overlap, were merged into a single category called “genito-pelvic pain/penetration disorder.” Although the DSM-5 merges some previous DSM sexual disorders, it is still useful to conceptualize persistent problems with sexual function in terms of four basic categories: 1. Sexual desire —Two DSM-5 –listed sexual dysfunctions ( female sexual interest/arousal disorder ; male hypoactive sexual desire disorder ) involve lack of interest in sex or aver- sion to sexual contact. 2. Sexual arousal —Two DSM-5 sexual dysfunctions involve problems with sexual arousal. In men, erectile disorder refers to a persistent difficulty in obtaining or sustaining erections sufficient to engage in satisfactory sexual activity. In women, the arousal component of female sexual interest/arousal disorder typically involves insufficient lubrication. 3. Orgasm —Three DSM-5 sexual dysfunctions involve problems related to orgasm. Female orgasmic disorder refers to persistent problems having an orgasm among women. In men, delayed ejaculation involves the inability to ejaculate, and premature (early) ejaculation involves reaching orgasm too quickly. 4. Sexual pain — One DSM-5 sexual dysfunction involves pain during sexual activity. Genito-pelvic pain/penetration disorder refers to women who experience pain in the vaginal area (often called dyspareunia ) and/or heightened muscle tension and fear of penetration, preventing or making intercourse painful (often called vaginismus ). The DSM-5 specifies that in order for a sexual problem or difficulty to be diag- nosed as a sexual dysfunction it must have occurred for a period of about six months or more, happen 75% to 100% of the time, and cause the person significant distress (American Psychiatric Association, 2013a). An exception is sexual problems that are caused by medications or substances, which do not require a minimum six-month duration to be labelled as a sexual dysfunction. Sexual dysfunctions are classified as lifelong or acquired (acquired dysfunctions follow periods of unproblematic function- ing), and as generalized or situational. Generalized dysfunctions occur in all situations. Situational dysfunctions affect sexual functioning only in some situations, such as during partnered sexual activity but not with solo masturbation, or with one partner but not another. Thus, if a man has never been able to obtain an erection during sexual activity with a partner but can do so during masturbation, his dysfunction is lifelong and situational.
Sexual Problems and Dysfunctions 357 Sexual Desire–Related Disorders Sexual dysfunctions that involve a lack of sexual desire affect both men (male hypo- active sexual desire disorder) and women (female sexual interest/arousal disorder). People with these conditions often report an absence of sexual thoughts or fantasies. The problem may be lifelong but usually follows periods of a regular desire for sexual activity. It may be generalized or may be situational, applying to a particular partner. A survey of 2000 American women (West et al., 2008) found that the incidence of low sexual desire was 26.7% for premenopausal women and 52.4% for postmenopausal women. The problem is more common among women than men. Nevertheless, the belief that men are always eager for sex is a myth (Hackett, 2008). Lack of sexual desire doesn’t imply that a person is unable to get an erection, lubricate adequately, or reach orgasm. Some people with low sexual desire can become sexually aroused and reach orgasm when adequately stimulated. Many enjoy sexual activity, even if they’re unlikely to initiate it. Many appreciate the affection and close- ness of physical intimacy but have no interest in genital stimulation. A lack of sexual interest or desire is one of the most common complaints related to sexual functioning. Yet there’s no clear consensus among clinicians and researchers about how to define “low sexual desire” (Heiman, 2008). How much sexual interest or desire is “normal”? There’s no standard level of sexual desire, and instances of low desire often become apparent only when there’s a discrepancy between levels of desire experienced by a couple. Although many women have strong levels of sexual desire, the literature on gender differences has suggested that men are generally more interested in sex than women are (Petersen & Shibley Hyde, 2011). As a result, when discrepancies in desire arise for heterosexual couples, the men are more likely than the women to have higher levels of desire. To the extent that gender differences in sexual interest levels exist, it’s been speculated that gay and lesbian couples may have fewer discrepancy troubles than heterosexual couples. When one member of a couple is more interested in sex than the other, sex therapists often recommend that the couple try to compromise. They also attempt to uncover and resolve problems in the relationship that may be dampening sexual ardour (Aubin, Heiman, Berger, Murallo, & Yung-Wen, 2009). When is lack of sexual desire a dysfunction? Not everyone has the same level of sexual desire as other men and women in the same age group. A person with a lower level of desire doesn’t necessarily have a sexual dysfunction. Remember, lack of desire should be classified as a dysfunction only when the person finds his or her level of sexual desire personally distressing. Basson (2010) suggested that many women can lead active, satisfying sex lives without ongoing or frequent feelings of desire between sexual engagements with their partners. Real Students, Real Questions Q What does the word “prude” mean? Is this considered a sexual dysfunction? A The word “prude” has the same origin as the word “proud,” and it refers to being highly or evenly excessively proper or modest in one’s own speech, behaviour, and dress. In other words, prudes prefer not to curse, kiss in public, or dress seductively. They also typically disapprove of such displays by others. What they do privately in a committed relationship might be quite dif- ferent. In fact, they might enjoy sex a great deal, so there is no necessary connection between public prudery and sexual function- ing or dysfunctioning. The origins of prudery are uncertain. Being reared strictly may have something to do with it, although many young people rebel, especially in open societies. RubberBall/SuperStock
358 Chapter 13 People with low sexual desire may have little or no interest in sex, but they are not repelled by genital contact. Some people, however, find sex disgusting or aversive and avoid such contact. A history of sexual trauma, such as sexual assault or childhood sexual abuse or incest, often figures prominently in cases of sexual aversion, especially in women (Colangelo & Keefe-Cooperman, 2012). Sexual Arousal–Related Disorders When we’re sexually stimulated, our bodies normally respond with vasocongestion , which produces erection in the male and vaginal lubrication in the female. People with sexual arousal–related disorders, however, fail to achieve or sustain the erections or lubrication necessary to facilitate sexual activity (Rowland & Incrocci, 2008). Or they lack the subjective feelings of sexual pleasure or excitement that typically accompany sexual arousal. In the past, problems with arousal were referred to as impotence in men and fri- gidity in women. These terms have come to be seen as unnecessarily negative, belit- tling, and unhelpful. Today health professionals use the less pejorative terms “erectile dysfunction” in men and “female sexual interest/arousal disorder” in women. MALE ERECTILE DISORDER Sexual arousal disorder in the male is called erectile disorder or erectile dysfunction. It’s characterized by persistent difficulty in achieving or maintaining an erection sufficient to allow completion of sexual activity. In most cases, the problem is limited to sexual activity with partners, or with some partners and not others. It can thus be classified as situational. In some cases, the dysfunction is found during any sexual activity, including masturbation. In such cases, it’s classified as gen- eralized. Some men with erectile dysfunction are unable to attain erections, while others can achieve but not sustain erections. vasocongestion Engorgement of blood vessels with blood, which swells the genitals and breasts during sexual arousal. erectile disorder Persistent difficulty getting or maintaining an erection sufficient to allow the man to engage in or complete sexual activity. Also termed erectile dysfunction. Real Students, Real Questions Q I do not feel sexual during times when I have a lot of schoolwork. Is that normal? A If “a lot of schoolwork” translates into stress, it is absolutely normal. Some people turn to sex as a way of trying to escape feelings of stress, but it is just as normal—and perhaps more common—for stress to have a dampening effect on sexual desire. Real Students, Real Questions Q I was molested as a child, and the thought of sex does not interest me. What can I do about this? A We will offer you some generalizations, but we will also admit, right at the outset, that we do not know enough about your particular situation to be more specific. We also suggest that you might want to talk the situation over with a helping professional who has expertise in the area. Having said that, you might begin by allowing a good rela- tionship to develop with a decent, caring person. If you are comfortable in the relationship and are engag- ing in some cuddling and so on, you might find some interest in sex developing. If such a relationship does not stir sexual feelings, it still would not hurt to discuss the situation with a professional. Also consider the possibility that your history of being abused may not be the cause of your current lack of interest in sex. RubberBall/SuperStock Corbis/SuperStock
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Sexual Problems and Dysfunctions 359 The incidence of erectile dysfunction increases with age. In a survey of Canadian men, Grover et al. (2006) found that about 30% of men in their 40s, a little over 40% in their 50s, and about 65% in their 60s have some degree of erectile dysfunction. A more recent survey of men in New Zealand found similar age-related rates of erectile dysfunction (Quilter, Hodges, Borman, & Coad, 2017). Occasional problems in achiev- ing or maintaining erection are quite common, happening to nearly all men. Fatigue, too much alcohol, anxiety over impressing a new partner, and other factors may cause occasional erectile difficulties. Even an isolated occurrence, however, can lead to a per- sistent problem if the man fears it will happen again. The more anxious and concerned he becomes about his ability to have an erection, the more likely he is to suffer with performance anxiety . This anxiety can contribute to repeated difficulty in gaining and maintaining an erection, resulting in a vicious circle of anxiety and erection problems. A man with erectile problems may try to achieve an erection by force of will, which can compound the problem. Each time it happens, it’s more demoralizing. He may ruminate about his sexual problem, setting the stage for yet more anxiety. His partner may try to comfort and support him by saying things like “It can happen to anyone,” “Don’t worry about it,” or “It will get better in time.” But attempts at reassurance may be to no avail. The vicious circle of anxiety and erectile failure may be interrupted if the man recognizes that occasional problems are normal and doesn’t overreact. However, the emphasis on sexual prowess in our culture may spur him to view occasional erectile problems as catastrophes, rather than transient disappointments. Viewing occasional problems as inconveniences, rather than tragedies, may help avert the development of persistent erectile difficulty. Performance anxiety is a prominent cause of erectile disorder. So are other psychological factors, including depression, lack of self-esteem, and problems with the relationship. Biological factors such as diabetes and heart disease can also play causal roles. In fact, medical conditions are frequently associated with erectile dysfunction, especially among middle-aged and older men (Grover et al., 2006). performance anxiety Feelings of worry about being able to function successfully with respect to sexual activity (or any other activity that might be judged by another person). The Emotional Toll of Erectile Disorder. Erectile disorder is characterized by persistent difficulty in achieving or maintaining an erection sufficient to allow the completion of sexual activity. Tens of millions of men in the United States and Canada experience some degree of erectile dysfunction, and the incidence increases with age. Occasional erectile problems are common and may be caused by fatigue, alcohol, or anxiety about a new partner. However, fear of recurrence can create a vicious cycle, in which anxiety leads to failure, and failure heightens anxiety. wavebreakmedia/Shutterstock
360 Chapter 13 It’s a common belief that sexual arousal is much simpler for men than for women. However, a focus group study (Jansen, McBride, & Yarber, 2008) suggested that men’s sex- ual arousal is also complex, and that there’s considerable variation in what men find arous- ing. The older men in the study reported that emotional connections with their partners were now more important than physical attractiveness when it came to sexual arousal. FEMALE SEXUAL INTEREST/AROUSAL DISORDER As previously noted, the DSM-5 replaced what was formerly known as female arousal disorder with the new classification of female sexual interest/arousal disorder because problems in the desire and arousal phases of female sexual response often overlap. For instance, women who experience a generalized lack of sexual desire are quite likely not to become sexually aroused easily. In other words, the desire and arousal phases of sexual response are closely intertwined for many women. As we discussed in Chapter 4, Basson’s (2008) intimacy-based model of sexual response suggests that some women, particularly those in longer-term relationships, may begin to experience sexual arousal that is sparked by feelings of intimacy with their partners rather than by a pre-existing sense of sexual desire. Thus, female sexual desire and arousal may not occur in a linear, step-by-step process. For many women, they may occur simultaneously, and it therefore makes more sense to conceptualize problems in these areas of sexual function together rather than as separate and distinct sexual dysfunctions. Some women may encounter persistent difficulties in becoming sexually excited or sufficiently lubricated in response to sexual stimulation. In some cases, these difficulties are lifelong. In others, they develop after periods of normal functioning. In some cases, difficulties are pervasive and occur during both masturbation and sex with partners. More often, they occur in specific situations. For example, they may occur with some partners and not with others, or during vaginal penetration but not during oral–genital sex or masturbation. According to Basson (2004), most women with arousal-related sexual dysfunctions experience little or no subjective arousal or sexual excitement. These women can be cat- egorized into two groups. Those with combined arousal problems experience no subjec- tive arousal and feel no genital response. Women with subjective arousal problems are aware that their genitals physically respond to stimulation but feel no subjective arousal. A minority of women can become aroused by many different kinds of stimuli but don’t find stimulation of their genitals arousing. They can still be highly interested in sex and become subjectively aroused as long as they experience non-genital stimulation (Basson, 2004). Arousal-related disorders may have physical causes. A thorough evaluation by a medical specialist is recommended. Any neurological, vascular, or hormonal problem that interferes with the lubrication or swelling response of the vagina to sexual stimula- tion may contribute to a sexual arousal–related disorder. For example, diabetes mellitus may lead to diminished sexual excitement, because the nerves that service the clitoris degenerate and the blood vessels become damaged. Reduced estrogen production can also result in vaginal dryness. Another interesting line of research has suggested that the skin of some women with sexual arousal problems is less sensitive to touch than the skin of women who don’t have such problems (Frohlich & Meston, 2005). Such women might seek to increase their sexual stimulation by psychological as well as physical means. Female sexual arousal–related disorders more often have psychological causes. In some cases, women may harbour deep-seated anger and resentment toward their part- ners (McCabe et al., 2010). Or they may fail to become aroused during sexual activity simply because they’re no longer sexually attracted to their partners, or because they’re experiencing nonsexual conflicts in their relationships. It would be incorrect to say these women have arousal disorders; rather than problems with sexual functioning, they have relationship difficulties. female sexual interest/arousal disorder An American Psychiatric Asso- ciation diagnosis that combines problems in sexual desire and becoming sexually aroused in women. These problems cause clinically significant distress.
Sexual Problems and Dysfunctions 361 Childhood sexual abuse is especially prevalent among women with sexual arousal– related disorders (Colangelo & Keefe-Cooperman, 2012). Survivors of sexual abuse often find it difficult to respond sexually to their partners. Feelings of helplessness, anger, or guilt—or even flashbacks of the abuse—may surface when these women begin sexual activity, undermining their ability to become aroused. Other psychosocial causes include anxiety and guilt about sex, and ineffective stimulation by the women’s part- ners (McCabe et al., 2010). Orgasmic Disorders Orgasmic disorders include female orgasmic disorder, delayed ejaculation, and prema- ture ejaculation. In female orgasmic disorder and delayed ejaculation, the individual is persistently delayed in reaching orgasm, or doesn’t reach orgasm at all, despite achiev- ing sexual stimulation that would normally be of sufficient intensity to result in orgasm. The problem is more common among women than men. In some cases, a person can reach orgasm without difficulty while engaging in sexual relations with one partner, but not with another. FEMALE ORGASMIC DISORDER Women with female orgasmic disorder are unable to reach orgasm or have difficulty reaching orgasm after what would usually be adequate sexual stimulation. Women who have never reached orgasm through any means are sometimes labelled anorgasmic or pre-orgasmic. A woman who reaches orgasm through masturbation or oral sex might not reach orgasm during intercourse with a male partner. Penile thrusting may not provide sufficient clitoral stimulation to facilitate orgasm. In other words, a woman who doesn’t reach orgasm during intercourse but can reach orgasm through other types of sexual stimulation doesn’t have an orgasmic disorder. University of Waterloo researcher B. J. Rye (2001) found that 93% of university women sometimes or usually needed direct clitoral stimulation during intercourse to reach orgasm. Only 46% of the women surveyed had orgasms during at least half of their intercourse experiences, and 49% said it often took them a long time to have orgasms. DELAYED EJACULATION The DSM-5 sexual dysfunction delayed ejaculation has also been called male orgasmic disorder, retarded ejaculation, and ejaculatory incom- petence. The problem may be lifelong or acquired, generalized or situational. Very few men have never ejaculated. In most cases, the disorder is limited to intercourse. The men may be capable of ejaculating during masturbation or oral sex but find it difficult or impossible to ejaculate during intercourse, despite high levels of sexual excitement. There’s a myth that men with delayed ejaculation and their partners enjoy this condition, because it enables them to “go on forever.” Actually, the experience is frustrating for both partners (Althof, 2012). Delayed ejaculation may be caused by physical problems, such as multiple sclerosis or neurological damage that interferes with neural control of ejaculation. It may also be a side effect of certain drugs. Various psychological factors may also play a role, including performance anxiety, sexual guilt, and hostility toward a partner. PREMATURE EJACULATION Men with premature ejaculation (PE) , also referred to as early ejaculation, or rapid ejaculation, ejaculate too quickly to permit their partners or themselves to fully enjoy sexual relations (Graziottin & Althof, 2011). Excluding erectile dysfunction in elderly men, premature ejaculation is the most common male sexual dysfunction (Lewis et al., 2010). The degree of rapidity varies. Some men ejaculate almost immediately after any form of sexual stimulation, even at the sight of their partners disrobing. But most men with this condition ejaculate either just before or immediately after penetration, or after a few penile thrusts. The DSM-5 stipulates that in order for a clinical diagnosis of PE to be made, ejaculation must occur within one minute of penetration (American Psychiatric Association, 2013a). female orgasmic disorder An American Psychiatric Asso- ciation diagnosis describing persistent or recurrent problems in women reaching orgasm. anorgasmic Unable to reach orgasm, through any means. delayed ejaculation A sexual problem in which a male persistently and recurrently has difficulty reaching orgasm, causing clinically significant distress. premature ejaculation (PE) A sexual dysfunction in which ejaculation occurs with minimal sexual stimulation, and before the man desires it. It’s also called “rapid” ejaculation.
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362 Chapter 13 Guy Grenier and Sandra Byers (2001) at the University of New Brunswick studied the ejaculatory behaviour of a community sample of men. The men reported that inter- course typically lasted for about eight minutes before they ejaculated. They also reported that ejaculation happened more quickly than they wished in about one third of their acts of sexual intercourse. They attempted to delay the timing of their ejaculations during about half of their intercourse experiences. In another study, involving 52 New Bruns- wick couples, Byers and Grenier (2003) compared the men’s and women’s reports of the men’s ejaculatory behaviour. There was only moderate agreement. The women tended to underestimate how seriously their male partners viewed PE. However, both the men and the women reported lower sexual satisfaction as a result of the men’s PE problems. The percentage of men experiencing PE varies, depending on the criteria the researchers use. Twenty-three percent of the men in Grenier and Byers’ (2001) study said they had problems with premature ejaculation. They ejaculated sooner than other men, perceived that they had less control over the timing of ejaculation, and were concerned about ejaculating earlier than they wished. Another Canadian study found a prevalence of PE ranging from 16% to 24%, depending on how PE was defined (Brock et al., 2009). The authors noted that 90% of the men with PE in their study had not discussed the problem with their doctors. Just what constitutes “premature”? There’s no clear cutoff. Some scholars have argued that the focus should be on whether the couple is satisfied with the duration of sexual activity, rather than on a specific time period. Helen Singer Kaplan (1974) suggested that the label “premature” be applied to cases in which men persistently or recurrently lack voluntary control over their ejacula- tions. This may sound like a contradiction in terms, given that ejaculation is a reflex, and reflexes needn’t involve thought or conscious control. Kaplan meant men might control their ejaculations by learning to regulate the amount of sexual stimulation they expe- rienced, keeping it below the threshold at which the ejaculation reflex was triggered. Sexual Pain–Related Disorders For most of us, sexual activity is a source of pleasure. For some of us, however, it causes pain and discomfort. With respect to sexual pain among women, the DSM-5 combines all sexual pain disorders into the single diagnostic entity of genito-pelvic pain/ penetration disorder (American Psychiatric Association, 2013a). The diagnosis can apply to both women and men. The problem has been broadly referred to as dyspareunia . Painful sex is less common in men and is generally associated with genital infec- tions that cause burning or painful ejaculation. Smegma under the penile foreskin of uncircumcised men may also irritate the penile glans during sexual contact. Painful sexual activity is particularly common among women, although about half of women with the problem do not seek professional help for it (Harlow et al., 2014). The location of the pain can vary. It can be at the entrance to the vagina, for example, in the vagina, or in the pelvic region (Pukall, Payne, Binik, & Khalife, 2003). Pain is usually a sign that something is physically wrong, and painful sex may result from physical causes, emotional factors, or an interaction of the two (Binik, 2005). On the other hand, lack of adequate lubrication is the most common cause of pain during sex. In this case, additional stimulation or artificial lubrication may help. 2 ❯ T / F Truth or Fiction Revisited Fiction. Actually, the most common cause of painful intercourse in women is not vaginal infection. It is lack of adequate lubrication. The normal changes of aging also commonly play a role in painful sex among perimenopausal and postmenopausal women (Ussher, Perz, & Parton, 2015). Vaginal infections or sexually transmitted infections (STIs) may produce painful sex. Allergic reactions to spermicides, even the latex material in condoms, can give rise to painful sex. genito-pelvic pain/penetration disorder An American Psychiatric Association diagnosis referring to a number of sexual pain problems in women and men. dyspareunia Persistent or recurrent pain during sexual activity.
Sexual Problems and Dysfunctions 363 Pain during deep thrusting may indicate endometriosis, pelvic inflammatory disease (PID), or structural disorders of the reproductive system. Two other sexual pain problems affect women: vulvodyinia and vaginismus (Simonelli, Eleuteri, Petruccelli, & Rossi, 2014). These terms were previously used by the American Psychiatric Association and are still used by many helping professionals. However, they are absent in the DSM-5 because there is so much overlap between these sexual pain conditions. A severe kind of sexual pain experienced by women (formerly called “vulvodynia” by the American Psychiatric Association and still referred to as “vulvodyinia” by many other professionals) is characterized by intense vulval pain, particularly chronic burning sensations, irritation, and soreness. There is commonly no identifiable cause— which can be highly frustrating—although a history of local infections, damage to local nerves, and allergies are among the suspects (Mayo Clinic, 2014). Cold compresses, local anaesthetics, and topical creams with estrogen or cortisone may provide relief (Mayo Clinic, 2014). The Mayo Clinic also recommends considering tricyclic antidepressants (you would be taking them “off label”—meaning for sexual pain and not for depres- sion), anticonvulsants, antihistamines (to reduce itching), biofeedback therapy (to learn to relax muscles in the pelvic floor), and in the most severe cases, nerve blocks or sur- gery. Consult your gynaecologist; you need not ignore this problem or try to go it alone. Although the American Psychiatric Association lumps this problem in with general sexual pain disorders, it should be noted that vulvodyinia is clearly medical in origin. Vaginismus has often been defined as the involuntary contraction of the vaginal muscles. However, research has indicated that it is heightened muscle tension and intense fear of penetration that distinguishes women with vaginismus from women with other types of genital pain such as dyspareunia (Lahaie et al., 2015). Heightened tension in the vaginal muscles is usually considered to be caused by psychological fear of penetration rather than physical injury or defect (Simonelli et al., 2014). It’s often been thought that vaginismus is a conditioned response to sexual trauma, but research has found that sexual trauma (e.g., sexual assault, vaginal injuries) is not more common among women with vaginismus compared to women with dyspareunia (Lahaie, Boyer, Amsel, Khalifé, & Binik, 2010). Women with vaginismus can be capable of sexual response and orgasm. However, fear of penetration triggers tension in the vaginal musculature at the point of penile insertion. vulvodyinia A problem characterized by symp- toms such as severe vulval pain, burning, and itching. vaginismus Vaginal pain accompanied by heightened muscle tension and fear of penetration. Origins of Sexual Problems and Dysfunctions Human beings are complex, with complex bodies and complex mental processes. We’re reared in families, within cultural settings. For these reasons, we need to consider possible biological, psychological, and social factors in sexual problems and dysfunc- tions, which can interact in a number of ways (Brown & Haaser, 2005). For example, biological and psychosocial factors—hormonal deficiencies, depression, dissatisfaction with a relationship, and so on—can contribute to lack of desire. Researchers refer to an Real Students, Real Questions Q Do women find a man ejaculating disgusting? Is that a dysfunction? A Some women find ejaculation disgusting. Others are turned on by it. Still others have no particular feelings about it. Finding ejaculating disgusting is not in itself a sexual dysfunction. If it gives rise to loss of sexual desire or difficulty becoming sexually aroused, it might contribute to one. Hogan Imaging/Fotolia
364 Chapter 13 approach that considers the interactions of biological, psychological, and sociocultural factors as a biopsychosocial model . Biological Causes LO 13.2 Discuss biological factors in the development of sexual problems and dysfunctions. Among the medical conditions that diminish sexual desire are testosterone deficiencies, thyroid overactivity, thyroid underactivity, and temporal lobe epilepsy (Ramasamy, Wilken, Scovell, Kovac, & Lipschultz, 2014). Sexual desire is stoked by testosterone, which is produced by men in the testes and by both men and women in the adrenal glands. Women may experience lower sexual desire when their adrenal glands are surgically removed (Cappalletti & Wallen, 2015). Low sexual interest, along with erectile difficulty, is also common among men with hypogonadism , which is treated with testosterone (Ramasamy et al., 2014). The reduction in testosterone levels that occurs in middle and later life may in part explain the gradual decline in male sexual desire (Ramasamy et al., 2014). Female sexual desire may also decline with age, however, because of physical and psycho- logical changes (Wierman et al., 2010). Some medications, especially those used to con- trol anxiety or hypertension, may reduce desire. Changing medications or doses may increase a person’s level of desire. People with sexual dysfunctions are generally advised to undergo physical exami- nations, to determine whether their problems are biologically based. For example, men with erectile disorder may be evaluated in sleep centres to determine whether they attain erections while they’re asleep. The technique is termed nocturnal penile tumescence (NPT). Healthy men usually have erections during REM sleep, which occurs every 90 to 100 minutes. Men with biologically based erectile disorder often don’t have nocturnal erections. A physical examination, particularly in the pelvic area, and assessment of hormone levels can uncover the root causes of some cases of sexual dysfunction among women. Medical investigation of a sexual dysfunction can lead to the discovery of an underlying medical condition that might otherwise remain unknown to the patient and his or her doctor. Fatigue may lead to erectile disorder and orgasmic dis- order in men, and to inadequate lubrication and orgasmic disorder in women, but these remain isolated incidents unless the person attaches too much meaning to them and becomes concerned about future sexual activity. HEALTH PROBLEMS Researchers find that health problems—especially cardiovascular disorders, hypertension, and obesity—contribute to several kinds of sexual dysfunction in men (Tan, Tong, & Ho, 2012), and particularly to sexual pain in women (van Lankveld et al., 2010). Painful sex often reflects an underlying infection. Medical conditions that affect sexual response include heart disease, diabetes mellitus, multiple sclerosis, spinal-cord injury, complications from surgery (such as removal of the prostate in men), hormonal problems, and the use of some medicines, such as those that treat hypertension and psychiatric disorders (Dan et al., 2014; Martin et al., 2014; Shafer, 2016). Even when biological factors are involved in sexual dysfunctions, psychological factors such as anger and depression can prolong or worsen them (Tan et al., 2012). biopsychosocial model An approach to explaining sexual problems and dysfunction that looks at the interactions of biologi- cal, psychological, and sociocul- tural factors. hypogonadism A condition marked by abnor- mally low levels of testosterone production. tumescence Swelling; erection. Too Tired for Sex. They were tired, and it didn’t happen. Should they keep trying, or wait until they’ve had a good night’s sleep? Chad Baker/Jason Reed/Ryan McVay/Photodisc/Getty Images
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Sexual Problems and Dysfunctions 365 Cardiovascular problems can lead to erectile disorder by affecting the flow of blood to and through the penis, a problem that becomes more common as men age. Damage to the nerves involved in erection can also play a role (Eardley et al., 2010). Erectile problems can arise when clogged or narrow arteries leading to the penis deprive it of oxygen (Miner, 2011). For example, erectile disorder is common among men with dia- betes mellitus, a disease that can damage blood vessels and nerves. Rimm (2000) studied 2000 men and found that erectile dysfunction was connected with a large waist, physical inactivity, and too much alcohol consumption (or no alcohol consumption!). The common condition among these men may have been high choles- terol levels. Cholesterol can impede the flow of blood to the penis, just as it impedes the flow of blood to the heart. Another study connected erectile dysfunction with heart disease and hypertension (Johannes et al., 2000). Sexual functioning in women seems to be less affected by cardiovascular disease. For both men and women, however, hypertension (high blood pressure) and the drugs used to treat it can negatively affect sexual functioning (Perez, Gadgil, & Dizon, 2009). Also, medications used to lower cholesterol, such as statins (e.g., Zocor, Lipitor), can contribute to erectile dysfunction (Trivedi et al., 2012). AGING Perimenopausal and postmenopausal women usually produce less vaginal lubrication than younger women, and their vaginal walls become thin—changes that can render sex painful (van Lankveld et al., 2010). These physical changes, along with negative stereotypes about older women and men, can create performance anxiety and discourage both partners from initiating sexual activity (Brotto et al., 2010; McCabe & Connaughton, 2014). In such cases, artificial lubrication can supplement the woman’s own production, and estrogen replacement may halt or reverse some of the sexual changes of aging (Wierman et al., 2010). However, the partners also need to have real- istic expectations and consider enjoyable sexual activities they can engage in without discomfort or high demands (Althof, 2010). The findings of the Massachusetts Male Aging Study suggested that men who exercise regularly seem to ward off erectile dysfunction (Derby, 2000). Men who burned 200 calories or more a day in physical activity—an amount that can be achieved by walking briskly for three kilometres—cut their risk of erectile dysfunction almost in half. Exercise seems to prevent clogging of the arteries, keeping them clear for the flow of blood into the penis. Nerve damage resulting from prostate surgery may impair erectile response (Koehler et al., 2012; Martin et al., 2014). Erectile disorder may also result from multiple sclerosis (MS), a disease in which nerve cells lose the protective coatings that facilitate transmission of neural messages (Keller, Liang, & Lin, 2012). MS has also been impli- cated in male orgasmic disorder. Medical conditions associated with advancing age, such as chronic kidney disease, hypertension, cancer, emphysema, and heart disease, can all impair erectile response, as can endocrine disorders that impair testosterone production (Shafer, 2016). Women can also develop vascular and nervous disorders that impair genital blood flow, reducing lubrication and sexual excitement, rendering intercourse painful, and reducing their ability to reach orgasm. All of these problems become more likely as people age. DRUGS Use of certain prescription and illicit drugs can contribute to sexual dysfunc- tion in both women and men. Antidepressant medications and antipsychotic drugs can impair erectile functioning and cause delayed ejaculation (Montejo, Montejo, & Navarro-Cremades, 2015). Tranquilizers such as Valium and Xanax may cause orgas- mic disorder in either sex. Some drugs used to treat high blood pressure can impair erectile response. Switching to other blood-pressure drugs or adjusting dosages may help. Other drugs that can lead to erectile disorder include adrenergic blockers, diuret- ics, cholesterol-lowering drugs (statins), anticonvulsants, anti-Parkinson drugs, and dyspepsia- and ulcer-healing drugs (Shafer, 2016).
366 Chapter 13 Central nervous system depressants such as alcohol, heroin, and methadone can reduce sexual desire and impair sexual arousal (del Rio, Cabello, & Fernandez, 2015; Shafer, 2016). Narcotics also depress testosterone production, thereby reducing sexual desire and leading to erectile dysfunction. Regular use of cocaine can cause erectile disorder or male orgasmic disorder and may reduce sexual desire in both men and women (Ciccarone, 2011; Hart et al., 2012). SSRIs AND SEXUAL RESPONSE People—especially physicians—need to be aware of the sexual side effects of some drugs used to treat depression. Selective serotonin reup- take inhibitors (SSRIs) are widely prescribed not only for depression, but also for panic disorder, obsessive-compulsive disorder, anorexia nervosa, and other conditions. Most physicians are aware that these drugs have some sexual side effects in some patients. However, they almost completely impair sexual arousal in many patients, especially older patients (Montejo et al., 2015). Moreover, even when patients discontinue the drugs, sexual functioning doesn’t necessarily bounce back. Some drugs that are helpful with depression may not impair sexual functioning—at least in the short run. Wellbutrin, for example, can improve sexual functioning and is sometimes prescribed along with an SSRI to help prevent sexual side effects. Psychosocial Causes LO 13.3 Discuss psychosocial factors in the development of sexual problems and dysfunctions. Abrupt changes in sexual desire are often explained by psychological and interper- sonal factors such as depression, stress, and problems in the relationship (McCabe & Connaughton, 2014; Stephenson & Meston, 2015). Anxiety is the most commonly reported factor. Sexual desire can be dampened by performance anxiety (anxiety over being evalu- ated negatively), anxiety involving fears of pleasure or loss of control, and deeper sources of anxiety relating to fear of injury (Janssen & Bancroft, 2006). Depression is also a com- mon cause (Laurent & Simons, 2009), and a history of childhood sexual abuse or sexual assault has been linked to low sexual desire (Colangelo & Keefe-Cooperman, 2012). Psychosocial factors connected with sexual dysfunction include cultural influences, economic problems, psychosexual traumas, dissatisfaction with relationships, lack of sexual skills, irrational beliefs, and performance anxiety (McCabe & Connaughton, 2014) (see Innovative Canadian Research: A Portrait of Great Sex for a discussion of a pleasure-focused rather than problem-focused approach to improving people’s sexual lives). CULTURAL INFLUENCES Children reared in sexually repressive cultural or home environments may learn to respond to sex with feelings of anxiety and shame, rather than anticipation and pleasure (Woo, Brotto, & Gorzalka, 2011). People whose parents instilled in them a sense of guilt over touching their genitals may find it difficult to accept their sex organs as sources of pleasure (McCarthy, Ginsberg, & Fucito, 2006). In most cultures, sexual pleasure has traditionally been a male preserve. Young women may be reared to believe sex is a duty they’re to perform for their husbands, not a source of personal pleasure. Although the traditional double standard has diminished in developed countries, some girls are still exposed to repressive attitudes (Allen, 2015; Rani & Sharma, 2015; Simmons, 2015). Women are more likely than men to be taught to suppress sexual desires. Self-control and vigilance—not sexual awareness and acceptance—become identified as feminine virtues. Women reared with such attitudes may not learn about their sexual potential or express their erotic desires to their partners. Many women who were exposed to negative attitudes about sex during childhood and adolescence find it difficult to suddenly view sex as a source of pleasure and sat- isfaction as adults. A lifetime of learning to turn themselves off sexually may impair sexual arousal and enjoyment when acceptable opportunities arise (Woo et al., 2011).
Sexual Problems and Dysfunctions 367 PSYCHOSEXUAL TRAUMA Women and men who were sexually victimized in childhood are more likely to have trouble becoming sexually aroused (Colangelo & Keefe-Cooperman, 2012; McCabe & Connaughton, 2014; Yehuda, Lehrner, & Rosenbaum, 2015). Some learning theorists have contended that conditioned anxiety explains many cases of sexual dysfunction. Sexual stimuli come to elicit anxiety when they’ve been paired with traumatic experiences, such as rape, incest, or sexual molestation. Unresolved anger, misplaced guilt, and feelings of disgust also make it difficult for victims of sexual trauma to respond sexually, even years later and with loving partners. EMOTIONAL FACTORS Pleasurable, fulfilling sexual activity with a partner typically involves allowing oneself to let go emotionally, at least to some extent. Fear of losing control or of letting go may make it more difficult for a person to let down his or her guard enough to become sexually aroused. Other emotional factors, especially depres- sion, are often implicated in sexual dysfunction (Laurent & Simons, 2009). Prolonged and high levels of stress can also interfere with sexual interest and response. MYTHS AND MISINFORMATION Although Western culture often seems to be satu- rated in superficial sexual imagery, many people grow up badly misinformed about sexuality. Sex-education programs in schools focus mainly on pregnancy and STI prevention and rarely teach about sexual response. Some non-Western cultural tradi- tions restrict and discourage learning about sexual pleasure, particularly for women. Because many, if not most, people have few credible and easily accessible sources of information about sexual functioning, it’s not surprising that myths and misinforma- tion about sexuality often prevail. In many cases, these are contributing factors in the development of sexual problems and dysfunctions. Providing corrective information is a key factor in overcoming them. INEFFECTIVE SEXUAL TECHNIQUES People who lack information about sexual- ity, and particularly about sexual response, are more likely to be unaware of what techniques are sexually pleasurable for themselves and their partners. For example, a woman who remains ignorant about the erotic importance of her clitoris may be unlikely to seek direct clitoral stimulation. People often make assumptions about what’s pleasurable for their partners on the basis of their own preferences and past experiences with previous partners. Based on his own preferences, for example, a man may assume he knows which techniques are pleasurable for his male partner, simply because they’re both men. As we’ll see, effective sexual communication is an important factor in the prevention and resolution of sexual problems and dysfunctions. BOREDOM AND ROUTINE It’s common for couples to fall into narrow sexual routines, in which the timing and sequence of sexual activity follow constant, famil- iar patterns. A couple may have sex only once they’ve gone to bed for the night, for example, and may always use the same one or two favoured positions or techniques. While some people remain sexually satisfied with standard routines, others find that, over time, their sexual relationships become monotonous. Once boredom and complacency about the sexual component of a relationship sets in, arousal often diminishes. LACK OF SEXUAL COMMUNICATION Partners who don’t communicate their sexual preferences or experiment with new techniques may find themselves losing interest. Canadian researchers MacNeil and Byers (2009) have examined how communicat- ing sexual likes and dislikes can affect sexual satisfaction within relationships. Their research indicated that, for both women and men, communicating sexual likes and dislikes contributes to greater sexual satisfaction within long-term relationships. Holmberg and Blair (2009) compared heterosexual, gay, and lesbian couples’ responses on a sexual communication scale (e.g., “My partner often complains that I am not very clear about what I want sexually.”). They found that levels of sexual
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368 Chapter 13 communication generally don’t differ among lesbian, gay, and hetero- sexual couples. In all of these relationship types, clear communication about sexual likes and dislikes may improve sexual satisfaction, while lack of such communication may lead to, or compound, existing sexual problems. RELATIONSHIP ISSUES Problems in a relationship are not easily left at the bedroom door (Brotto et al., 2010; Moore & Heiman, 2006). Heterosexual and gay and lesbian couples alike usually find that sex is no better than other facets of their relationships (Matthews, Hughes, Tartaro, Omoto, & Kurtzman 2006). Partners who have trouble com- municating in general may also be unable to communicate their sexual desires. Couples who harbour resentments may make sex one of their conflict areas. They may not allow themselves to become aroused by their partners, or they may withhold orgasm to express their resentment (McCabe & Connaughton, 2014). The following hypothetical cases highlight how sexual problems or dysfunctions can develop against the backdrops of troubled relationships. A Vicious Cycle. Conflict in a relationship may dampen sexual interest, and lack of sexual interest may further strain the relationship. BananaStock/Thinkstock/Getty Images Alia and Fernando met in university, when they were both in their early 20s. After graduation, they moved into an apartment together. At first, the sexual component of their relationship was characterized by passion and discovery. After a few years, however, tensions began to build in their relationship, as conflicts around finances, when and whether they’d have children, and other domestic issues began to emerge. For Fernando, having sex with Alia was a way to restore intimacy between them, and he frequently tried to initiate sex after they argued. Alia, on the other hand, was reluctant to have sex when she and Fernando had been arguing. Even when their relation- ship was going well, Alia was slower to respond to sexual stimulation than Fernando. Now, as conflict in their relationship has grown, Alia finds that she has difficulty becoming aroused when they do have sex, which Fernando finds both frustrating and hurtful. Alia feels under increasing pressure to respond sexually to Fernando, as she senses that her lack of arousal is making their relationship problems worse. Both Alia and Fernando are committed to making their relationship work. What began as a series of problems in other aspects of their relationship, however, has now spread to their sexual relationship. Kim and Lisa have been in a relationship for several years. Kim grew up in a family with a cultural tradition that didn’t accept lesbian sexuality. She only fully accepted that she was a lesbian in her mid-30s. Lisa, on the other hand, readily embraced her lesbian identity, and proudly came out to her friends and family when she was 16. From the beginning, Lisa took a more assertive role in most aspects of the relationship. She feels very much in touch with her sexuality and has a clear sense of what her turn-ons are. Although Kim has always been happy that Lisa seems to be so enthusiastic about their sex life, she’s been less certain about her own likes and dislikes in the bedroom, and it seems to her that she may not enjoy exactly the same sexual activities as Lisa. Over time, Kim has begun to resent Lisa, complaining that their relationship is increasingly one-sided. Kim’s growing sense of resentment has spilled over into their sex life, as she’s increasingly unable to have an orgasm when they have sex. Huang and Mila are a middle-income couple in their 40s with three children. Like many couples, they struggle with the financial obligations of maintaining their house- hold. Mila has enjoyed some degree of career success, and her income has gradually increased. Huang, on the other hand, has seen his career stall, and his income has failed to grow at the same pace as Mila’s. Mila and Huang frequently argue about family finances. Huang’s self-esteem has declined, and he feels that Mila’s putting pressure on him to pull his weight financially. Mila and Huang’s sexual relationship has been reasonably satisfying for both of them, though Huang has had occasional difficulties getting and maintaining an erection when he’s having sex with Mila. Lately, however, as
Sexual Problems and Dysfunctions 369 their arguments about money have become more intense, Huang finds that he’s unable to achieve an erection with Mila. PERFORMANCE ANXIETY Anxiety—especially performance anxiety—plays an important role in sexual dysfunction (Althof et al., 2014; Althof & Needle, 2011). Performance anxiety occurs when a person becomes overly concerned with how well he or she performs a certain act or task. Performance anxiety may place a dysfunctional individual in a spectator role, rather than a performer role. Rather than focusing on erotic sensations and allowing reflexes such as erection, lubrication, and orgasm to occur naturally, the person focuses on self-doubts and thinks, “Will I be able to do it this time? Will this be another failure?” In men, performance anxiety can either inhibit erection or trigger rapid ejacula- tion (Althof et al., 2014). Erection is mediated by the parasympathetic nervous system and can be blocked when anxiety activates the sympathetic nervous system. Because ejaculation, like anxiety, is mediated by the sympathetic nervous system, arousal of this system can increase the level of stimulation and heighten the potential for rapid ejaculation. Performance anxiety can reduce vaginal lubrication and contribute to female orgas- mic disorder (Goldstein, Meston, Davis, & Traish, 2006). Women with performance anxieties may try to force orgasm, only to find that the harder they try, the more elusive it becomes. As its name suggests, performance anxiety often involves the thought that sexual activity with a partner is a “performance,” similar to what an actor does on stage or screen. When we think of sex as a performance, we’re more likely to judge ourselves as performing well or inadequately. When we’re able to conceptualize sex as an undemanding exchange of pleasure, rather than as a performance, we may feel less anxiety. OTHER FACTORS Using data from the Canadian Contraception Study, researchers at the University of Western Ontario found a number of factors related to common sexual concerns in women (Gruszecki, Forchuk, & Fisher, 2005). Higher body weight was asso- ciated with low sexual desire and infrequent orgasm during intercourse. These sexual issues could be due to health issues, as well as to self-esteem issues connected with body weight. Married women, older women, and those with higher levels of education were also more likely to report low desire. Solutions for Sexual Problems and Dysfunctions LO 13.4 Describe the PLISSIT and Masters and Johnson approaches to addressing sexual problems and dysfunctions. The most common approaches to sex therapy are cognitive and behavioural. Cognitive- behavioural sex therapy aims to modify dysfunctional cognitions (beliefs and attitudes) and behaviours as directly and as quickly as possible. Sex therapists also recognize the roles of childhood conflicts and the quality of current relationships, so they draw on various forms of therapy, as needed (Adams, 2006; Althof, 2010; Althof et al., 2014; Kleinplatz, 2012). Sex therapy usually involves both partners, although individual ther- apy is preferred in some cases. Although the particular approaches vary, sex therapy generally aims to change self-defeating beliefs and attitudes, enhance sexual knowledge, improve sexual communication, teach sexual skills, and reduce performance anxiety. Recent research has shown that sex therapy is effective for treatment of lack of sexual interest or desire in women, and also in female orgasmic disorder sex therapy A collective term for behav- ioural models for treating sexual dysfunctions.
370 Chapter 13 (Frühauf, Gerger, Schmidt, Munder, & Barth, 2013). Sex therapy may involve partners, although individual therapy is preferred in some cases. Therapists find that granting people “permission” to sexually experiment or discuss negative attitudes about sex helps many people overcome sexual problems without the need for more intensive therapy. Today, biological treatments have also been emerging for various sexual problems. Most public attention has been focused on Viagra and Cialis, drugs that are helpful in most cases of erectile dysfunction. But Addyi, a drug meant to boost women’s sexual desire, has joined the arsenal. Biological treatments for other sexual problems are also emerging. Moreover, there are research findings to the effect that psychotherapy combined with drugs such as Viagra and Cialis can be more effective than the medicine alone (Schmidt, Munder, Gerger, Fruhauf, & Barth, 2014). In this section we explore psychological and behavioural approaches to the treatment of sexual problems. The PLISSIT Model Developed by Annon (1976), the PLISSIT model is used by many therapists to address the sexual concerns of their clients (Faubian & Parish, 2017; Ohl, 2007; Timm, 2009). This model allows health professionals and their clients to differentiate between sexual problems that can be resolved through basic education and counselling and problems that require intensive or specialized sex therapy. The PLISSIT model consists of four escalating levels: • Permission (P)—At the first level, the therapist gives the client permission to talk about sexuality and personal concerns. The therapist often asks exploratory ques- tions, to bring out the relevant issues and put the client at ease. • Limited information (LI)—Some sexual problems may be rooted in myths and misin- formation about sexuality. Providing a limited amount of correct information about sexual functioning is often a key step in resolving a problem. • Specific suggestions (SS)—Once the basic nature of a sexual problem is identified, the therapist provides suggestions to help resolve it. The client may be encouraged to read books about sexual enhancement, for example, such as sex manuals, or to watch instructional sex videos or erotica. With a basic understanding of the client’s sexual issues, the therapist may also make suggestions for incorporating specific sexual techniques or suggest ways the couple can refocus their sexual interaction. • Intensive therapy (IT)—If the first three levels of therapy are unsuccessful in solving the problem, a more intensive form of sex therapy may be required. At this point, a therapist who doesn’t specialize in sex therapy will refer the client to someone with advanced training in treating sexual dysfunction. The Masters and Johnson Approach Masters and Johnson pioneered the use of direct behavioural approaches to treating sexual dysfunction (Masters & Johnson, 1970). A female-and-male therapy team focuses on the couple as the unit of treatment during a two-week residential program. Masters and Johnson considered the couple dysfunctional, not the individual. A couple may describe the male partner’s erectile disorder as the problem, but it’s likely to have led to other problems by the time the couple seeks therapy. Similarly, a man whose female partner has an orgasmic disorder is likely to be anxious about his ability to provide effective sexual stimulation. Masters and Johnson developed their approach with heterosexual couples, so it’s uncertain how well it applies to same-sex couples. There’s no reason, however, to
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Sexual Problems and Dysfunctions 371 believe a focus on couple dynamics would be less effective with lesbian and gay couples than with heterosexuals. In this approach, anxieties and resentments are aired, but the focus of treatment is behavioural change. A couple performs daily sexual homework assignments, such as sensate-focus exercises . Sensate-focus sessions are carried out in the nude. Partners take turns giving and receiving stimulation in non-genital areas. Without touching the breasts or genitals, the giver massages or fondles the receiving partner, to provide pleasure under relax- ing, undemanding conditions. Because genital activity is restricted, there’s no pressure to “perform.” The giving partner is free to engage in trial-and-error learning about the receiving partner’s sensate preferences. The receiving partner is free to enjoy the experience, without feeling rushed to reciprocate or obliged to respond by becoming sexually aroused. The receiving partner’s only responsibility is to direct the giving partner, as needed. In addition to these general sensate-focus exercises, Masters and Johnson used specific assignments to help couples overcome particular sexual dysfunctions. Integrating Sex Therapy and Psychotherapy Sex therapy, as noted, has cognitive components—for example, addressing self-defeating attitudes and expectations, and sex education. Few therapists use strict Masters and Johnson guidelines anymore, but many of their innovations are incorporated into their methods (Althof, 2010). Moreover, because sexual activity is so often embedded in rela- tionships, many therapists (Althof, 2010) use psychotherapy and couple therapy to help sensate-focus exercises Exercises in which sexual partners take turns giving and receiving pleasurable stimulation in non- genital areas. APPLIED KNOWLEDGE HOW DO YOU FIND A QUALIFIED SEX THERAPIST? How do you locate a sex therapist, if you think you have a sexual dysfunction? Because the provinces don’t regulate use of the term “sex therapist,” it’s essential to determine that a sex therapist is a member of a recognized profession—such as psychology, social work, medicine, or marriage and family counselling—and has had training and supervision in sex therapy. Professionals are usually licensed or certified by their provinces. All provinces require licensing of psychologists and physicians, but some don’t license social workers or marriage counsellors. Only physicians are permitted to bill their provincial health plans for providing sex therapy. If you’re uncertain how to locate a qualified sex therapist in your area, contact your university or college psychology depart- ment, health department, or counselling centre; a medical or psychological association; a marriage and family therapy asso- ciation; or a family physician. Relatively few people in Canada have been trained as specialists in sex therapy. The only Canadian organization that certifies sex therapists specifically is the Board of Examiners in Sex Therapy and Counselling in Ontario (BESTCO), which includes professionals from diverse backgrounds with clinical expertise in human sexual concerns. Quebec has licensed sexologists. Some Canadian therapists are also certified by American- based organizations such as the American Association of Sex Educators, Counselors, and Therapists (AASECT) and the Society for Sex Therapy and Research (SSTAR). It’s a good idea to ask a therapist the following: • What discipline(s) has she or he been educated in? • Where did she or he earn degrees, and what are those degrees? • Is she or he licensed or certified? • What fees does she or he charge? • What treatment plans does she or he use? • What training has she or he received in human sexuality and sex therapy? These questions are important because there’s such a wide diversity in professional backgrounds and training for sex thera- pists. Accordingly, the types of treatments and services they offer vary enormously. If the therapist becomes uncomfortable, asks why you’re asking such questions, or fails to provide a direct answer, beware. Remember, under no circumstances is it ethical for a professional therapist to engage in any form of sexual activity with a client.
372 Chapter 13 couples learn how to share the power in relationships, how to improve sexual communication, and how to negotiate dif- ferences. The combination of sex therapy and couple therapy appears to be a powerful tool for enhancing relationships as well as sex lives. (See Applied Knowledge: How to Find a Qualified Sex Therapist and Applied Knowledge: Promoting Eroticism in Sex Therapy.) The Treatment of Specific Sexual Problems and Dysfunctions LO 13.5 Outline the treatment of specific sexual problems and dysfunctions. TREATMENT FOR LOW SEXUAL DESIRE (FEMALE SEXUAL INTEREST/AROUSAL DISORDER; MALE HYPOACTIVE SEXUAL DESIRE DISORDER) Some sex therapists help kindle sexual appetites in people with low sexual desire by prescribing self-stimulation exercises combined with erotic fantasies. Sex therapists also assist dysfunctional couples by prescribing sensate-focus exercises, enhancing communication, and expanding the couples’ repertoires of sexual skills. Sex therapists recognize that low sexual desire is often a complex problem that requires more intensive treatment than problems of the arousal or orgasm phases. Coun- selling or psychotherapy may be helpful in treating low sexual desire and sexual aver- sion, by uncovering and resolving psychological conflicts (Carvalho & Nobre, 2010). Cognitive-behavioural therapy approaches may be helpful in addressing low desire in women (Hucker & McCabe, 2015; Jones & McCabe, 2012), and mindfulness-based techniques can also be helpful. (See A World of Diversity: An Alternative Approach to Enhancing Female Sexuality, p. 382.) Some cases of low sexual desire in men involve hormonal deficiencies, especially deficiencies in testosterone. Testosterone replacement therapy can increase desire in some men with low testosterone levels (Brock et al., 2015). Among women, as among men, lack of sexual desire can be connected with low levels of androgens. There is some evidence that for postmenopausal women with low desire, treatment with testoster- one patches can be effective (Achilli et al., 2017). It should be noted, however, that the testosterone patch Intrinsa, which is designed to treat low desire in postmenopausal and maintaining erections. Viagra does not induce sexual desire. Rather, it helps men who already desire sex to get an erection. The most common sexual problem reported by women is lack of sexual desire, or lack of interest in sex. Many women with low sexual desire don’t believe they have a problem, but others would like to have more of a sex life, either for their own sake, for their partner’s, or both. Unlike Viagra and other drugs that have been shown through clinical trials to help many men “rise” to the occasion as needed, flibanserin, which must be taken daily, seems to have a moderate effect at best in improving women’s sexual functioning. In one trial, for example, women who took the drug In its traditional gender-stereotyped colour, the “little pink pill” for women was approved for use by the Food and Drug Administra- tion (FDA) in the United States in 2015 and by Health Canada in 2018. The drug flibanserin (brand name, Addyi) has been widely perceived, and often described in the media, as the female coun- terpart to the traditional, gender-stereotyped blue pill—Viagra. Except it wasn’t, and it isn’t. Viagra and the similar drugs Cialis and Levitra enhance (most) men’s abilities to obtain and maintain an erection by capturing men’s blood flow into the penis. That is, Viagra, in its complicated biochem- ical way, contributes to a man’s sexual arousal, making satisfactory sexual activity possible for many men who have problems getting A CLOSER LOOK THE “LITTLE PINK PILL” FOR WOMEN Working With LGBTQ Couples. Therapists who work with LGBTQ couples find many problems similar to those of heterosexual cou- ples, but in some cases, sexual and relationship issues may reflect the couple’s sexual orientation. Custom Medical Stock Photo/Alamy Stock Photo
Sexual Problems and Dysfunctions 373 women, has been approved for use in Europe but not in Canada or the United States. When lack of desire is connected with depression, sexual interest may rebound when the depression lifts. Treatment in such cases may involve psychotherapy, rather than sex therapy. When problems in the relationship are involved, couples therapy may be required, to improve the relationship. Once interpersonal problems are ironed out, sexual interest may return. Treatments for Sexual Arousal–Related Disorders Men with persistent problems getting an erection may believe they’ve “forgotten” how to have one. Erection is an involuntary reflex, however, not a skill. 3 ❯ T / F Truth or Fiction Revisited Fiction. Men with ED are actually taught that it is not possible to “will” an erection. One can only set the stage for erection (or vaginal lubrication) to occur and then allow it to happen reflexively. In sex therapy, women who have trouble becoming lubricated and men who have erectile problems learn that they needn’t do anything to become sexually aroused. As long as their problems are psychologically and not organically based, they need only receive sexual stimulation under relaxed circumstances, so anxiety doesn’t inhibit their natural reflexes. Pearson Education the answer is political. The FDA rejected applications to market the drug in 2010 and 2013, but women’s advocates argued that the FDA was showing a gender bias in denying women the drug. Several drugs to help men had been approved, but none for women. On the physical risk–reward side, the drug has shown some moderate positive effects, and the side effects, while potentially serious, are not thought to be deadly and don’t affect every user equally. Men’s drugs also have side effects and are also not uniformly effective for all men with erectile dysfunction. Now that flibanserin has been approved for use in the United States and Canada information about its effectiveness will continue to accumulate. Users will tell other women about their experiences with it. We can’t say the jury is out; the drug was approved. We can say that in the next few years a clearer picture of the benefits and risks of flibanersin will likely emerge. In the meantime, it is also likely that other drugs to help women with sexual problems and dysfunctions will be coming on the market. Canadian sex researchers Peggy Kleinplatz (2003) and Rosemary Basson (2000) have been vocal in their opposition to what they view as the medicalization of female sexuality. Indeed, other, nonbiological factors are often involved in sexual dysfunction, including intimacy and relationship issues, and if these aren’t addressed, a sexual problem will likely persist even if sexual dysfunction drugs are used. Other Canadian researchers have also been skeptical of a purely pharmaceutical approach to treating women’s sexual problems, noting that female sexual desire and arousal are complex, multi-factorial biological and psychological processes, and it’s therefore unlikely that a single drug can be an effective treatment (Chivers & Brotto, 2017). reported having 4.4 “satisfying sexual experiences a month” as compared with 3.7 satisfying experiences for women who took a placebo (Editorial Board, 2015; Thorp, Palacios, Symons, Simon, & Barour, 2014). Then there are the side effects, including the potential for low blood pressure and loss of consciousness. Drinking alco- hol increases these risks, and the drug is to be taken daily, not upon demand. Doctors and pharmacists cannot prescribe or dis- pense it without taking an online tutorial and demonstrating that they understand the risks. Moreover, it is known that the drug boosts the action of the neurotransmitter serotonin in the brain (Stahl, 2015), but many drugs do that and their exact actions on sexual desire remain somewhat unclear. So, if the drug is risky and its effects are “underwhelming,” why was it approved and why is it being prescribed? Part of
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374 Chapter 13 To reduce performance anxiety, the partners engage in undemanding sexual contacts that don’t demand lubrication or erection. They may start with non-genital sensate-focus exercises, in the style of Masters and Johnson. After a couple of sessions, sensate focus extends to the geni- tals. The position shown in Figure 13.1 allows the woman easy access to her partner’s genitals. The partner repeatedly teases him to erection and allows the erection to subside. The partner thereby avoids creating performance anxiety that could lead to erection loss. By repeatedly regaining his erection, the man loses his fear that losing an erection means it won’t return. He also learns to focus on erotic sensations for their own sake. He experiences no demand to perform, because the couple is instructed to refrain from intercourse. Even when the partner experiencing dif- ficulties can reliably become sexually excited (denoted by erection in the male and lubrication in the female), the couple doesn’t immediately attempt intercourse; this might rekindle perfor- mance anxiety. Rather, they engage in a series of undemanding, pleasurable sexual activities, which eventually culminates in intercourse if that’s what they desire. With Masters and Johnson’s approach, the couple begin intercourse after about 10 days of treatment. The woman teases the man to erection while she sits above him, straddling his thighs. When he’s erect, she inserts the penis (to avoid fumbling attempts at entry) and moves slowly back and forth in an undemanding way. Neither attempts to reach orgasm. If the man loses his erection, the two repeat the teasing and intercourse. Once the partners become confident that the man can retain his erection—or reinstate it, if he loses it—they may gradually increase coital thrusting, to reach orgasm. BIOLOGICAL APPROACHES TO TREATING ERECTION PROBLEMS IN MEN (ERECTILE DISORDER) The world’s attention has recently been focused on biologi- cal approaches to treating erectile disorder. Biological or biomedical approaches can be helpful, especially when organic factors are involved. Oral medications consisting of compounds called phosphodiesterase type-5 inhibi- tors (or PDE-5 inhibitors for short) are by far the most popular biological treatment for erectile problems. These drugs—sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis)—relax the muscles that surround the small blood vessels in the penis, allow- ing them to dilate so blood can flow into them more freely. After taking the drug, a man must still be aroused through manual, oral, or other stimulation for an erection to occur. The amount of time it takes to become effective varies with the drug. Viagra can become effective within half an hour and is effective for up to four hours. The oral form of tadalafil (Cialis) becomes effective in about half an hour and lasts for up to 36 hours. Users in France have dubbed it “the weekender.” The most common side effects of these drugs are facial flushing, stuffy nose, and headache, sometimes including migraine. These drugs shouldn’t be used by individuals taking any type of nitrate drug, such as nitroglycerine, due to the risk of developing potentially life-threatening low blood pressure. Viagra was hailed as an important new treatment for erectile dysfunction when it hit the market in early 1998. A study published in the New England Journal of Medicine tested Figure 13.1 A Behavioural Approach to Treating Erectile Disorder. In one part of a sex therapy program designed to overcome erectile disorder, a man’s partner repeatedly teases him to erection and allows the erection to subside. This avoids the creation of performance anxiety that could lead to his losing the erection. Through repeatedly regaining his erection, the man loses his fear that losing an erection means it won’t return.
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Sexual Problems and Dysfunctions 375 the effects of Viagra on more than 800 men with erectile dysfunction caused by both psychological and organic factors (Goldstein et al., 1998). In one phase of the study, 69% of attempts to engage in intercourse were successful for men taking Viagra, compared to 22% for men taking a placebo. A Canadian study (Carrier, Morales, & Defoy, 2005) found that Viagra was still effective for men who had been taking it for three years. There’s ample evidence that these oral medications are effective for most men (Yuan et al., 2013). In a study by the University of Western Ontario’s William Fisher and his colleagues (2005), many women whose partners had erectile dysfunction reported that they expe- rienced lower levels of sexual desire, arousal, orgasm, and sexual satisfaction. A sig- nificant proportion of the women whose partners used an erection drug experienced increased sexual desire, arousal, and orgasm. Nevertheless, it should be noted that while a sexual dysfunction in either partner can negatively affect a couple’s sexual life, research has also shown, for example, that for men in their 50s in stable long-term rela- tionships, erectile dysfunction does not necessarily affect overall relationship happiness (Rosen, Heiman, Long, Fisher, & Sand, 2016). Hormone treatments can also be effective in treating some cases of erectile dysfunction. Testosterone helps restore the sex drive and erectile ability in many men who have abnormally low levels of testosterone (Brock et al., 2015). There’s no evidence that hormone therapy helps men who already have normal hormone levels. Various other treatments are available, such as vascular surgery on the penis, penile implants (see Figure 13.2), penile injections with alprostadil (brand names Caverject and Edex) or phentolamine (Invicorp), penile suppositories (brand name MUSE), and a vacuum pump held over the penis to increase blood flow. Relatively few men use Real Students, Real Questions Q I know that Viagra helps put more blood into the penis, but how does it do that? How does it actually work? A The answer is chemical and it applies to Levitra and Cialis as well as Viagra. The end point is to allow the arteries in the penis to dilate and fill up with blood to produce an erection. Chemically, what has to happen for arteries to dilate is that the brain sends a signal along a nerve fibre ending in a nonadrenergic–noncholinergic (NANC) cell in an artery; the NANC cell produces nitric oxide and injects it into the bloodstream and nearby cells. The nitric oxide causes a chemical called cyclic guanosine monophosphate (cGMP) to be produced, which relaxes the muscles that line an artery, increasing the flow of blood. However, a chemi- cal called phosphodiesterase (PDE) deactivates cGMP. The specific type of PDE found in the penis is called PDE5. Viagra, Levitra, and Cialis are all PDE5 inhibitors. That is, they work by deactivating PDE5. Step by step: 1. A man takes Viagra, Levitra, or Cialis. 2. The chemical in the pill circulates throughout his bloodstream. 3. The chemical attaches to PDE5 in his penis and deactivates most of it. 4. When he is sexually aroused, his brain sends the usual message to the cells in his penis, resulting in the output of nitric oxide. 5. In turn, the nitric oxide produces cGMP. 6. Because most PDE5 has been deactivated, cGMP builds up, allowing the arteries in the penis to dilate and produce a fuller erection. Note: Although Viagra and its chemical cousins are marketed as PDE5 inhibitors, their effects are somewhat broader, which is why they sometimes produce migraines. Stockbroker/SuperStock
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376 Chapter 13 these techniques, however, because they’re not very practical or comfortable to use. Research has indicated that a relatively new treatment for erectile dysfunction called low-intensity external shockwave lithotripsy, in which a probe is applied to the penis to increase blood and thereby improve erectile function, can be an effective treatment for some men (Lu et al., 2017). APPROACHES TO AROUSAL PROBLEMS IN WOMEN (FEMALE SEXUAL INTEREST/ AROUSAL DISORDER) As noted above, the DSM-5 (American Psychiatric Associa- tion, 2013a) has combined the former categories of female arousal disorder and female hypoactive desire disorder because problems in these areas of female sexual function tend to overlap. Factors that negatively affect desire often also affect arousal. As with other sexual problems and dysfunctions, treatment for problems with arousal includes addressing contributing factors such as excessive alcohol use, rela- tionship issues, and use of SSRI antidepressants. Psychological treatments such as sensate-focus exercises and masturbation training centred on women becoming more self-focused and assertive can be helpful (Faubian & Parish, 2017). Mindfulness-based cognitive therapy has also been found to be effective in addressing sexual arousal problems in women (Brotto & Basson, 2014) (see A World of Diversity: An Alternative Approach to Enhancing Female Sexuality). Some cases of female sexual arousal problems involve impaired blood flow to the genitals. Female sexual arousal involves vaginal lubrication, which permits sexual activity without a great deal of painful friction. Lubrication is made possible by vaso- congestion—the flow of blood into the genitals. Lack of lubrication can reflect the physical effects of aging, menopause, or surgically induced menopause. Sometimes all that’s necessary to deal with lack of lubrication is an artificial lubri- cant such as K-Y Jelly or other commercially available lubricants designed to enhance sexual activity. But lessened blood flow to the genitals can also sap sexual pleasure, and thereby lessen a woman’s desire for sex. The development of effective biological treatments for female sexual dysfunction has lagged behind the development of treatments for men. Some have speculated that this is because female sexual response tends to be tied more directly to psychosocial influences, such as relationship factors. Nevertheless, researchers continue to search for medical treatments to enhance female arousal. For example, researchers are inves- tigating the use of alprostadil (a vasodilator) for use with women, in the form of a cream that’s inserted into the vagina to enhance the flow of blood and hence lubrication. Other biological treatments for women include testosterone skin patches. There’s even a device called Eros that creates gentle suction over the clitoris, increasing vasoconges- tion and sexual sensations. (See Figure 13.3.) ( See A Closer Look: The “Little Pink Pill” for Women for information on flibanserin, a new drug to treat low desire in women.) After Viagra was shown to be highly effective in treating erectile dysfunction in men, researchers began investigating the potential benefits of Viagra for women. Reviews of the research have not shown a consistent positive effect of Viagra in women with arousal disorders (Chivers & Rosen, 2010). However, the research does indicate that Viagra may be useful for women who experience arousal difficulties caused by antidepressant medications (Nurnberg, Hensley, & Heiman, 2008). Because of their general lack of effectiveness, neither the FDA in the United States nor Health Canada has approved the use of Viagra or other similar drugs targeting male erectile dysfunc- tion for the treatment of female arousal problems. ADDRESSING DIFFICULTIES HAVING AN ORGASM IN WOMEN (FEMALE ORGASMIC DISORDER) Women who have never experienced orgasm often harbour negative attitudes about sex that cause anxiety and inhibit sexual response. Treatment in such cases may first address these attitudes. For women who have difficulty having an orgasm only when having sex with their partner or partners, involving partners in treatment is recommended. Use of Figure 13.2 A Penile Implant. A penile implant provides erection when a man’s cardiovascular system doesn’t do the job. Cylinders are implanted in the penis and a fluid reservoir (shown at top left) is placed near the bladder. A pump (shown in lower middle) is typically inserted in the scrotum. Squeezing the pump forces fluid into the cylinders, inflat- ing the penis. Tripping a release valve later returns the fluid to the reservoir, deflating the penis. Courtesy of NuGyn Inc Figure 13.3 A Clitoral Device for Stimulating Vasocongestion. This device works by creating gentle suction over the clitoris, stimulating blood flow into the woman’s genitals. This allows vaginal lubrication, which in turn facilitates sexual activity. Larry Mulvehill/The Image Works.
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Sexual Problems and Dysfunctions 377 the PLISSIT model as well as behavioural therapies such as directed masturbation, sensate-focus exercises, or a combination of these has been shown to be effective (Laan, Rellini, & Barnes, 2013). Although there are few studies examining their effectiveness, limited research has suggested that vibrator use can be helpful in treating arousal and orgasm problems (Harvard Women’s Health Watch, 2017). The Masters and Johnson method is a couples-oriented approach to treating anorgasmic women. It begins with sensate-focus exercises. Then, during genital massage and later during intercourse, the woman guides her partner in the caresses and movements she finds sexually exciting. Taking charge helps free the woman from the traditional stereotype of the passive, subordinate female role. 4 ❯ T / F Truth or Fiction Revisited True. Many sex therapists do recommend masturbation as a treatment for women who have never been able to reach orgasm (Cohen & Goldstein, 2016). Masturbation allows people to get in touch with their sexual responses at their own pace. The sexual pleasure they experience helps to counter lingering sexual anxieties. The Masters and Johnson approach recommends a training position (see Figure 13.4) that gives one partner access to the other’s breasts and genitals. She can APPLIED KNOWLEDGE PROMOTING EROTICISM IN SEX THERAPY Ottawa sex therapist Peggy Kleinplatz (2003) has developed an innovative approach to sex therapy. She argues that most sex therapy is too focused on treating symptoms and solving problems, and should focus instead on personal growth, which includes enhancing sexual relationships and erotic potential. Kleinplatz is especially concerned about the focus on pills and devices. She argues that the medical model emphasizes per- formance measures such as frequency and firmness of erections, and ignores the quality of interactions (e.g., satisfaction, intimacy). Kleinplatz presents a thorough critique of the field of sex therapy in her 2012 book New Directions in Sex Therapy: Inno- vations and Alternatives . She believes many therapists are personally uncomfortable with promoting eroticism and attempt only to enable couples to engage in the mechanics of sexual intercourse, rather than helping them maximize sexual pleasure (Kleinplatz, 2012). This mechanical approach results in sexual boredom for many couples, who come to rely on specific routines for achieving orgasm and are then afraid to risk trying new, pos- sibly more fulfilling approaches. According to Kleinplatz (2003), many people want to excite their partners and establish deep, sensual connections that will bring more intense sexual ecstasy. Eroticism, in her view, is the key to maintaining sexual desire. The erotic encounter should focus on pleasure for its own sake, rather than on the tension release of orgasm (Kleinplatz, 2003). Figure 13.4 The Training Position for Undemanding Stimulation of the Female Genitals. This position gives the woman’s part- ner access to her breasts and genitals. She can guide her partner’s hands, to show him or her what types of stimu- lation she enjoys.
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378 Chapter 13 guide their hands, to show them the types of stimulation she enjoys. The genital play is undemanding . The goal is to learn to provide and enjoy effective sexual stimulation, not to reach orgasm. The clitoris is not stimulated early, because doing so may produce a high level of stimulation before the woman is prepared. After a number of occasions of genital play, the couple has intercourse in the woman on top position. (See Figure 13.5.) This position allows the woman freedom of movement and control over her genital sensations. She is told to regard the penis as her toy. She and her partner engage in several sessions of deliberately slow thrusting, to sensitize her to sensations produced by the penis and to break the common, coun- terproductive pattern of desperate, rapid thrusting. Orgasm cannot be willed or forced. When a woman receives effective stimulation, feels free to focus on erotic sensations, and feels that nothing is being demanded of her, she will generally reach orgasm. Once she’s able to attain orgasm in the woman on top position, she and her partner may extend their sexual repertoire to other positions. Masters and Johnson preferred working with the couple in cases of anorgasmia. Other sex therapists prefer to begin working with the woman individually, and suggest masturbation as therapy. Masters and Johnson worked with heterosexual couples, but placing the focus on undemanding genital play may be equally applicable to lesbian couples in which one of the partners has difficulty reaching orgasm. Masturbation allows individuals to get in touch with their sexual responses at their own pace. Many sex therapists recommend that women having difficulty with orgasm focus on masturbation. It frees them of the need to rely on, or please, a partner. The sexual pleasure they experience helps counter lingering sexual anxieties. Although there is some Figure 13.5 The Woman on Top Position. In treatment for female orgasmic disorder, the couple has intercourse in the woman on top position after a number of occasions of genital play. This position allows the woman freedom of movement and control over her genital sensations. She’s told to regard the penis as her toy. She and her part- ner engage in several sessions of deliberately slow thrusting, to sensitize the woman to sensations produced by the penis and to break the common, counterproductive pattern of desperate, rapid thrusting.
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Sexual Problems and Dysfunctions 379 variation, the following elements are commonly found in directed masturbation programs for women: • Education —The woman and her partner (if she has one) are educated about female sexuality. • Self-exploration —Self-exploration is encouraged as a way of increasing the woman’s sense of body awareness. She may hold a mirror between her legs to locate her sexual anatomic features. • Self-massage —The woman creates a private, relaxing setting for self-massage. She begins to explore the sensitivity of her body to touch, discovering and repeating the caresses she finds pleasurable. She may use non-alcohol-based oils and lotions to enhance the sensuous quality of the massage and provide lubrication for the external genitalia. To prevent performance anxiety, the woman doesn’t attempt to reach orgasm during the first few occasions. • Self-permission —The woman may be advised to challenge lingering guilt and anxi- ety about sex in general and self-pleasuring in particular. For example, she might reassure herself that experiencing sexual pleasure is a natural and positive part of life, giving herself permission to enjoy it. • Fantasy —Arousal is heightened through the use of sexual images, fantasies, and fantasy aids, such as erotic books or videos. • A vibrator —Millions of women use vibrators, either during solo masturbation or with their partners. Because vibrators may provide more intense stimulation, they can be useful for women seeking to have orgasms more easily. • Partner involvement —After the woman is capable of regularly achieving orgasm through masturbation, the focus may shift to her sexual relationship with her part- ner. She can teach her partner how to stimulate her in ways that enable her to reach orgasm. Our focus has been on sexual techniques, but a combination of approaches that focus on sexual techniques and underlying interpersonal problems may be more effec- tive than focusing on sexual techniques alone, at least for couples whose relationships are troubled. TREATMENT FOR MEN WHO HAVE DIFFICULTY EJACULATING (DELAYED EJACULATION) Treatment for delayed ejaculation generally focuses on increasing sexual stimulation and reducing performance anxiety (Althof, 2012). The Masters and Johnson approach has the couple practise sensate-focus exercises for several days, dur- ing which the man makes no attempt to ejaculate. The couple is then instructed to bring him to orgasm any way they can, usually by having the partner stroke the man’s penis. Once he can ejaculate in his partner’s presence, the partner brings him to the point at which he’s about to ejaculate. Then, if the couple is heterosexual, they use the woman on top position, with the woman thrusting vigorously to bring him to orgasm. TREATMENT FOR MEN WHO EJACULATE TOO QUICKLY (PREMATURE EJACULATION) Available treatments for premature ejaculation consist of three main approaches: behavioural therapy, drug therapy, and a combination of behavioural and drug therapies. The Masters and Johnson approach to treating premature ejaculation is an exam- ple of a behavioural therapy in which sensate-focus exercises are followed by practice in the training position shown in Figure 13.1. The partner teases the man to erection, masturbates him, and uses the squeeze technique when he indicates that he’s about to ejaculate. The partner holds the penis between the thumb and the first two fingers of one hand. The thumb presses against the frenulum. The fingers straddle the coro- nal ridge on the other side of the penis. The partner squeezes the thumb and squeeze technique A method for treating premature ejaculation. The tip of the penis is squeezed to temporarily prevent ejaculation.
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380 Chapter 13 forefingers together fairly hard for about 20 seconds until the man’s urge to ejaculate passes. The couple repeats this process three or four times in a 15- to 20-minute ses- sion before the man purposely ejaculates. The squeeze technique is used for a num- ber of sessions until the man gradually learns to tolerate higher levels of sexual stimulation without ejaculating. Once this process results in a longer time to ejacula- tion, the couple graduates to other forms of sexual activity, such as oral sex, penile– vaginal intercourse, or anal intercourse, with the squeeze technique applied as the man nears ejaculation. 5 ❯ T / F Truth or Fiction Revisited True. In using the squeeze technique, the partner holds the penis between the thumb and first two fingers of the same hand. The thumb presses against the frenulum. The fingers straddle the coronal ridge on the other side of the penis. Squeez- ing the thumb and forefingers together fairly hard for about 20 seconds (or until the man’s urge to ejaculate passes) prevents ejaculation. The erect penis can withstand fairly strong pressure without discomfort, but erection may be partially lost. There is little evidence, however, that this technique is a long-term solution to premature ejaculation. Another behavioural therapy, the alternating stop–start method for treating prema- ture ejaculation, was introduced by urologist James Semans (1956). The method can be applied to manual stimulation or other forms of sexual activity. For example, the partner can manually stimulate the penis until the man is about to ejaculate. He then signals his partner to suspend sexual stimulation, and allows his arousal to subside before stimulation is resumed. This process enables him to recognize the cues that precede his point of ejaculatory inevitability, or point of no return, and to tolerate longer periods of sexual stimulation. When the stop–start technique is applied to penile–vaginal intercourse or anal intercourse, the partner stays relatively still and the man withdraws if he feels he’s about to ejaculate. As the man’s sense of control increases, more vigorous thrusting can begin. The couple again stops thrusting when the man signals that he’s approaching ejaculatory inevitability. The stop–start method is used each time the couple engages in sexual activity until the man is able to prolong his time to ejaculation. Although the squeeze and stop–start techniques have been widely recommended as methods to alleviate premature ejaculation, there’s little research showing that, when used without the addition of biological treatments, they’re effective, particularly for men with severe or persistent cases (Sharlip, 2005). While these techniques may be more useful for men with mild cases of premature ejaculation, emphasis is increasingly being placed on biological treatments. BIOLOGICAL TREATMENTS FOR PREMATURE EJACULATION Some drugs that are usually used to treat psychological problems can be effective in treating premature ejacu- lation (McMahon, 2011). Clomipramine, which is used to treat obsessive-compulsive dis- order and schizophrenia, can impair erectile response at high doses. But in a study with 15 couples, low doses helped men engage in intercourse five times longer than usual with- out ejaculating (Althof, 1994). Antidepressant drugs have also been helpful in the treatment of premature ejaculation, but are associated with erectile dysfunction (Waldinger, 2011). Why do drugs used to treat psychological problems help with premature ejacula- tion? The psychological problems are frequently connected with imbalances in body chemicals, such as neurotransmitters—the chemical messengers of the brain. Neu- rotransmitters are also involved in other bodily functions, including ejaculation. Anti- depressant drugs (e.g., SSRIs) all work by increasing the action of the neurotransmitter serotonin. Serotonin, in turn, may inhibit the ejaculatory reflex (Waldinger, 2011). But note the cautions about using SSRIs we discussed earlier in the chapter. There is also evidence that PDE-5 inhibitors (e.g., Viagra) can be an effective treat- ment for premature ejaculation, especially if they are used in conjunction with SSRIs (Martyn St. James et al., 2017).
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Sexual Problems and Dysfunctions 381 Overall, from a review of the research on various treatments for premature ejacula- tion, Cooper et al. (2015) concluded that there is limited evidence that physical behav- ioural techniques (e.g., squeeze and stop–start) used by themselves are effective, and that while drug therapies can be beneficial, the most effective approach is to combine behavioural techniques with drug therapies. TREATMENTS FOR SEXUAL PAIN PROBLEMS IN WOMEN (GENITO-PELVIC PAIN/ PENETRATION DISORDER) Dyspareunia, or painful intercourse, generally calls for medical intervention, to identify and treat any underlying physical problems that might cause pain, such as urinary-tract infections (van Lankveld et al., 2010). (See Innovative Canadian Research: Treatment for Provoked Vestibulodynia.) Vaginismus is generally treated with behavioural exercises in which fingers or plastic vaginal dilators of increas- ing size are inserted to help relax the vaginal musculature (Reissing, 2012). A gynaecolo- gist may first demonstrate insertion of the narrowest dilator. Later, the woman practises inserting wider dilators at home. She increases the size of the dilator as she becomes capable of tolerating insertion and containment for 10 or 15 minutes without discomfort or pain. Vaginal dilators are also used to treat dyspareunia. The woman herself—not her partner or her therapist—controls the pace of treat- ment. The woman’s or her partner’s fingers (first the littlest finger, then two fingers, and so on) may be used in place of the plastic dilators, with the woman controlling the speed and depth of penetration. When the woman is able to tolerate dilators (or fingers) equivalent in thickness to a penis or dildo, the couple may attempt penetration. Still, the woman should control insertion. Circumstances should be relaxed and undemanding. The idea is to avoid re-sensitizing her to fears of penetration. INNOVATIVE CANADIAN RESEARCH TREATMENT FOR PROVOKED VESTIBULODYNIA Canadian researchers have been at the forefront of research on chronic dyspareunia caused by provoked vestibulodynia (PVD), which is characterized by a sharp, burning pain of at least three months’ duration experienced when direct pressure is applied just inside the vaginal opening. It’s estimated that up to 15% of premenopausal women experience chronic dyspareunia, and most cases are attributable to PVD (van Lankveld et al., 2010). As might be expected, PVD can have serious negative conse- quences for the sexual lives of affected women and their part- ners (Basson, 2016). A team of Canadian and American researchers led by Sophie Bergeron and Yitzchak Binik of McGill University (Bergeron et al., 2001) conducted controlled studies of the effectiveness of cognitive-behavioural therapy, biofeedback, and surgery involv- ing the excision of the vestibular area. The findings indicated that both psychological and surgical interventions can be useful in the treatment of dyspareunia. Bergeron and others from the Uni- versity of Quebec (Bergeron, Khalifé, Glazer, & Binik, 2008) did a follow-up study with participants from the original samples. Treat- ment gains were still maintained for each intervention. Over this longer period, however, cognitive-behavioural therapy was found to be as effective as surgery in reducing levels of reported pain during intercourse. Women who held negative attitudes toward sex and sexual pleasure responded less favourably to the surgery. More recently, Canadian researchers have focused their attention on psychological and physical therapies to treat PVD. Psychological treatments for PVD focus on both the expe- rience of pain and its numerous psychosexual consequences, including reduced sexual desire and arousal (Reissing, Binik, Khalifé, Cohen, & Amsel, 2004). Cognitive-behavioural–based psychological interventions are currently among the most popu- lar therapies for PVD (Dunkley & Brotto, 2016). Lori Brotto and her colleagues from the University of British Columbia (Brotto, Basson, Driscoll, Smith, & Sadownik, 2015) developed and evaluated a four-session group therapy program for women with PVD that focused on building mindfulness meditation skills, information, and cognitive-behavioural skills. Women with PVD who participated in the sessions showed improvement in both psychological and physiological measures of pain. Quebec-based researchers at the Université de Sherbrooke and Université de Montréal (Morin, Carroll, & Bergeron, 2017) conducted a systematic review of studies on the effectiveness of pelvic-floor physical therapy methods for decreasing pain for women with PVD. The results indicated that physical therapy methods such as biofeedback, dilators, electrical stimulation, education, and multidisciplinary approaches were effective for decreasing pain during intercourse and improving sexual function.
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382 Chapter 13 A WORLD OF DIVERSITY AN ALTERNATIVE APPROACH TO ENHANCING FEMALE SEXUALITY by Lori A. Brotto, PhD, Department of Obstetrics and Gynaecology, University of British Columbia Treatment approaches designed to help women with sex- ual problems have generally focused on improving sexual response. A healthy sexual response, however, doesn’t necessarily sig- nify overall sexual satisfaction or lack of sexual distress. Specifi- cally, 5.5% of American women aged 30 to 79 reported that sexual activity is unsatisfying (Lutfey et al., 2009), despite the fact that they experienced no difficulties with desire, arousal, or orgasm. In the Global Study of Sexual Attitudes and Behaviors (Laumann et al., 2005), 8% to 18% of the 40- to 80-year-old women reported not finding sex pleasurable. Some women therefore weren’t sexually satisfied, even though the mechanics of sexual response were operating and the women didn’t meet the criteria for a sexual dysfunction. INNOVATIVE CANADIAN RESEARCH A PORTRAIT OF GREAT SEX Most research on human sexuality focuses on sexual problems, rather than sexual pleasure. In contrast, Ottawa researcher Peggy Kleinplatz and her colleagues (2009) interviewed people who reported experiencing “great sex” with the objective of building a conceptual model that would outline the key charac- teristics of optimal sexuality. Many of the people participating in the study were over the age of 60, and some had been in relationships for 25 years or longer. In describing great sex, many of them were drawing on several decades of experience with sex and relationships. Per- haps younger people have something to learn from the wisdom of those with more experience. Eight major components of great sex emerged from the interviews: • Being present, focused, and embodied —The most basic characteristic of great sex was being totally immersed in and intensely focused on the experience. This led to total surrender of the body to the experi- ence, without any other distracting thoughts. • Connection, or being in sync —A strong sense of con- nection and a feeling of synchronicity was an important component of great sex for many of the participants. As one woman said, it’s a feeling of “two people being in the right head space at the right time together, being able to share that” (Kleinplatz et al., 2009, p. 6). • Deep sexual and erotic intimacy —Regardless of whether the sexual encounters occurred in long-term or other kinds of relationships, there was a powerful sense of intimate engagement and trust in the relation- ships. As one participant suggested, “It’s part of the way you act with each other long before you’re actu- ally engaged in any kind of, you know, technical sex” (Kleinplatz et al., 2009, p. 6). • Extraordinary communication and heightened empathy —Being able to communicate, both verbally and nonverbally, and being tuned in to their partners’ responses were seen by some as crucial to great sex. • Authenticity —Participants felt they could be free to be themselves and open about their own desires. They spoke of feeling totally uninhibited and transparent. • Transcendence and transformation —Some participants indicated that great sex was a “high” similar to what can be experienced through meditation. Others noted that great sex with a partner could be transformative, carrying over in a positive way to other aspects of life. • Exploration and interpersonal risk-taking —Great sex was seen as an ongoing process of discovery, with the partners continuing to explore their sexuality over time. This required taking some personal risks in exploring new things. Many participants stressed that sexual exploration was done with a sense of fun and humour. • Vulnerability —Freely allowing themselves to be vulnerable was, for some participants, an impor- tant aspect of great sex. An older male participant believed vulnerability was what distinguished good from great sex: In normal good sex or good relationships, I think there’s always some maybe small but detectable barriers, some things held back. In great sex, I think those for me disappear, and so that one is quite transparent to the other person, and therefore quite vulnerable, but it feels, it goes with an intensely erotic and good feeling, rather than a scary feeling. (Kleinplatz, Peggy J., Event Code: 200 Management dynamics; 310 Science & research, The components of optimal sexuality: a portrait of “great sex”. 2009. The participants emphasized that they had developed their ability to experience great sex over time, in some cases many years. For many, their perceptions of great sex changed with their life experiences and personal growth.
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Sexual Problems and Dysfunctions 383 These women (Ogden, 2007) described their sexual expe- riences as boring, dry, and unemotional. In response to this situation, Ogden (2007) called for a non-goal-oriented, spiritual element to sexuality. Eastern techniques, with their origins in the Kama Sutra of the fourth to sixth centuries, might provide some of the spiritual dimensions the traditional Western approaches lack. One Eastern technique that might improve women’s sexuality is mindfulness. Mindful Meditation Mindfulness involves nonjudgmental, present-moment awareness. It has roots in Buddhist meditation. Although it’s a non-religious practice, transcending all organized religions, it does have a spiri- tual component (Carmody, Reed, Kristeller, & Merriam, 2008). Recently, mindfulness has been incorporated into a brief, psycho-educational treatment program for women with disorders of sexual desire and arousal, and found to be effective as part of a larger treatment program that includes education, cognitive and behavioural skills, and couples-therapy exercises. In the study, women who used a combination of in-session and at-home exer- cises evaluated the mindfulness component as the most valuable aspect of treatment (Brotto & Heiman, 2007). Specifically, mindfulness was introduced to women by giving them instructions about how to be mindful in their nonsexual lives. They were introduced to the topic with the following: Many of us go through life not living in the present moment. We fluctuate between thinking in the future (worrying, plan- ning, thinking), and living in the past (reviewing past events, conversations, plans). We miss out on valuable and meaning- ful experiences in the present. We have evolved to multi-task, and this reinforces mindlessness. However, in instances when we wish to be present, such as the sexual scenario, it’s dif- ficult if not impossible for us to turn off the cerebral chatter. The net effect is a reduction in arousal, thereby making the sexual experience less rewarding and pleasurable. SOURCE: Used with permission from Lori A. Brotto, PhD, Department of Obstetrics and Gynaecology, University of British Columbia. The heart of mindfulness is practising the body scan exer- cise, which involves attending to the sensations in specific parts of the body. Women can practise the body scan a few times a week, in addition to practising mindfulness every day, usually for 10 minutes, during other activities (e.g., eating, driving, having a conversation, playing a sport or instrument). They’re also given a set of body-focused mindfulness exer- cises to practise at home. The first is a focusing exercise. The women are asked to visually attend to their bodies during and after their baths or showers. They’re encouraged to describe what they see in non- judgmental ways, and are given a list of possible statements to repeat during the exercise, such as “My body is my own,” “My body is alive,” and “I appreciate the following aspects of my body.” The self-observation exercise asks women to use hand- held mirrors to observe their genitals. They’re reminded that this is a nonsexual exercise, with the goal of allowing them to remain in the present while letting any judgments about them- selves, their bodies, or how they’re struggling with the exercise to float away. The self-observation and touch exercise asks women to gen- tly touch their own genitals while repeating the self-observation exercise. After some weeks of practice, a sexual goal is added. The woman is encouraged to repeat the self-observation-and-touch exercise while imagining herself as a competent sexual, femi- nine, sensual woman. There’s then a discussion about incor- porating mindfulness while being sexual, either alone or with a partner. Several studies have tested the efficacy of a mindfulness-based sex therapy intervention for women with low desire and arousal. These studies found a significant improve- ment in sexual response and a decrease in sexual distress (see Brotto, 2013; Brotto & Basson, 2014). Mindfulness techniques therefore show great promise in treating women’s sexual con- cerns, and may fill the spiritual gap for some women who have unsatisfying sexual experiences.
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Chapter Review LO 13.1 Describe the prevalence and types of common sexual problems and dysfunctions. Sexual problems are common among young adult and older Canadians. Among midlife Canadians the most com- mon sexual problem is low levels of sexual desire. A sex- ual dysfunction is a persistent or recurring lack of sexual desire or difficulty becoming sexually aroused or reaching orgasm. The most widely used system of classification for sexual dysfunctions is the American Psychiatric Associa- tion’s Diagnostic and Statistical Manual of Mental Disorders (DSM), which lists four types of sexual disorders related to sexual desire, sexual arousal, orgasm, and sexual pain. Sex- ual desire–related disorders involve dysfunctions in sexual desire, interest, or drive. The individuals experience a lack of sexual desire or an aversion to genital sexual contact. In men, sexual arousal disorders involve recurrent difficulty in getting or sustaining erections sufficient to successfully engage in sexual intercourse. In women, they typically involve failure to become sufficiently lubricated. Women are more likely to encounter difficulties reaching orgasm, and men are more likely to have trouble with premature ejaculation. Sexual pain disorders can include dyspareunia, vaginismus, and vulvodynia. LO 13.2 Discuss biological factors in the development of sexual problems and dysfunctions. Fatigue may lead to erectile disorder in men, and to orgas- mic disorder and dyspareunia in women. Dyspareunia often reflects inadequate lubrication, vaginal infections, and STIs. Organic factors are believed to be involved in the majority of cases of erectile disorder. Medications and other drugs may also impair sexual functioning. Aging can impair sexual functioning, as well. LO 13.3 Discuss psychosocial factors in the develop- ment of sexual problems and dysfunctions. Psychosocial factors connected with sexual dysfunction include cultural influences, psychosexual traumas, marital dissatisfaction, psychological conflicts, lack of sexual skills, irrational beliefs, and performance anxiety. LO 13.4 Describe the PLISSIT and Masters and Johnson approaches to addressing sexual problems and dysfunctions. The PLISSIT model is used by many therapists to address the sexual concerns of their clients and consists of four escalating levels: permission, limited information, specific suggestions, and intensive therapy. Sex ther- apy aims to modify behaviours directly by changing self-defeating beliefs and attitudes, fostering sexual skills and knowledge, enhancing sexual communication, and providing behavioural exercises to enhance sexual stimulation while reducing performance anxiety. Masters and Johnson pioneered the direct, behavioural approach to treating sexual dysfunction. Some sex therapists help kindle sexual appetites in people with inhibited sexual desire by prescribing self-stimulation exercises combined with erotic fantasies. LO 13.5 Outline the treatment of specific sexual problems and dysfunctions. Cognitive-behavioural therapy and mindfulness-based techniques may be helpful in addressing low desire in women. Men and women with impaired sexual arousal receive sexual stimulation from their partners under relaxed circumstances, so anxiety doesn’t inhibit their natural reflexes. Biological treatments such as the drug Viagra are the most common treatment for male erectile disorder. Masters and Johnson used a couples-oriented approach in treating anorgasmic women. Other sex thera- pists prefer a program of directed masturbation, to enable women to learn about their own bodies at their own pace and free them of the need to rely on partners or on pleas- ing partners. Premature ejaculation is most effectively treated with a combination of behavioural techniques (e.g., squeeze and stop–start) and drug therapies. Dyspareunia, or painful intercourse, is generally treated with artificial lubricants and medical interventions. Vaginismus and dyspareunia can be treated with a series of dilators.
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Sexual Problems and Dysfunctions 385 Test Your Learning Multiple-Choice Questions 1. In order to qualify as a sexual dysfunction, a sexual problem must __________. (a) be caused by a medical condition (b) reduce the sexual pleasure of the person and their partner(s) (c) persist over time and cause the person distress (d) prevent the person from reproducing 2. According to the study of Canadian adults by Brock et al. (2006)., what percentage of people with sexual function problems sought help from health professionals? (a) 0 (b) 25 (c) 50 (d) 75 3. Permission and specific suggestions are components of __________. (a) an insight-oriented approach to treating low desire (b) the Masters and Johnson approach to sex therapy (c) the biological treatment of sexual dysfunction (d) the PLISSIT model 4. According to a study by Kleinplatz and colleagues (2009), which of the following was not found to be a key component of great sex? (a) expertise in performing oral sex (b) erotic intimacy (c) communication (d) exploration and interpersonal risk-taking 5. __________ is a common cause of erectile difficulties. (a) Orgasm anxiety (b) Ejaculatory incompetence (c) Performance anxiety (d) Hyposensitivity of the penis 6. Heightened muscle tension and fear of penetra- tion that makes intercourse painful or impossible is known as __________. (a) dyspareunia (b) vaginismus (c) phimosis (d) anorgasmia 7. A low level of __________ can lessen sexual desire. (a) testosterone (b) sildenafil (c) Depo-Provera (d) alprostadil 8. Which of the following is not one of the psychosocial factors associated with sexual dysfunction? (a) dissatisfaction with the relationship (b) lack of sexual skills (c) anxiety due to a previous negative experience (d) side effects of prescription drugs 9. A behavioural approach to treating sexual disorders might include all of the following except __________. (a) adjusting hormone balance to improve sexual functioning (b) changing self-defeating beliefs and attitudes (c) enhancing sexual knowledge (d) improving communication skills 10. Sex therapists are most likely to recommend mastur- bation as a treatment for __________. (a) premature ejaculation (b) female orgasmic disorder (c) vaginismus (d) delayed ejaculation Answers: 1. c; 2. b; 3. d; 4. a; 5. c; 6. b; 7. a; 8. d; 9. a; 10. b
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386 Chapter 14 Sexually Transmitted Infections Learning Objectives STIs in Canada LO 14.1 Identify and discuss key features and recent trends in STIs in the Canadian population. Bacterial STIs LO 14.2 Describe the transmission, effects, and treatment of chlamydia. LO 14.3 Describe the transmission, effects, and treatment of gonorrhea. LO 14.4 Describe the transmission, effects, and treatment of syphilis. Vaginal Infections LO 14.5 Describe the transmission, effects, and treatment of vaginal infections. Viral STIs LO 14.6 Describe the transmission, effects, and treatment of HIV and AIDS. LO 14.7 Describe the transmission, effects, and treatment of genital herpes. LO 14.8 Describe the transmission, effects, and treatment of viral hepatitis. LO 14.9 Describe the transmission, effects, and treatment of human papillomavirus. Ectoparasitic Infestations LO 14.10 Describe the transmission, effects, and treatment of ectoparasitic infestations. STI Epidemiology: Biological, Psychological, and Social Factors LO 14.11 Identify and assess the roles of different biological, psychological, and social factors in the epidemiology of STIs in Canada. Ocean Photography/Veer
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Sexually Transmitted Infections 387 Harry and Carin, both 20, have been seeing each other for about a month. They feel strong sexual attraction toward each other, but haven’t become sexually intimate, in part because of fears about sexually transmitted infections (STIs) . Harry believes using condoms is no guarantee against infection, and wants the two of them to be tested for HIV and other sexually transmitted infections. Carin has resisted undergoing these tests, partly because she feels insulted that Harry fears that she may be infected, and frankly, partly in fear of the test results. She’s heard that symptoms of many STIs may not be visible, or may not develop for years after infection. She wonders whether she might have been infected by one of the men she’s had sex with in the past. Keisha has genital herpes. A 19-year-old pre-law student, she’s had no recurrences since her initial outbreak, two years ago. She knows, however, that herpes is a lifelong infection that may recur from time to time. She also knows she may inadvertently pass the herpes virus along to her sex partners. She’s begun thinking seriously about Steve, a man she’s been dating for the past month. She’d like to tell him she has herpes before they become sexually intimate, yet she fears that telling him might scare him off. José, 21, is a math and computer science major. He lives off campus with several buddies, in a run-down house they’ve dubbed “the Nuclear Dumpsite.” He’s been seeing Bill, a history major, for several months. They’ve begun having sexual relations and have practised safer sex—at least, most of the time. During the past week José has noticed some odd-looking bumps around his penis that didn’t seem to be there before. For now, he’s adopting a wait-and-see attitude, hoping they’ll go away, but in the back of his mind he wonders whether he should see a doctor. Scenarios like these play out thousands of times each year on college and university campuses across Canada. If you have an STI, think you might have one, or are worried that you’re at risk for infection, you’re not alone. STIs are more common than most of us think. The World Health Organization estimates that more than 357 million people around the world are infected with STIs each year (World Health Organization, 2016). STIs are something many of us prefer not to think or talk about with friends and inti- mate partners, mainly because it would involve frank discussions about sexual behav- iour, which Western culture has often discouraged. Many people—if not most—lack even a basic knowledge of STIs and their own personal risks for infection. Although discussions about STIs often focus on their medical implications, when someone learns she or he has an STI, the emotional impact can be as great as—if not sexually transmitted infection (STI) An infection that’s passed from one person to another through sexual contact. (Some STIs, such as HIV, can also be transmitted in other ways.) TRUTH OR FICTION? Which of the following statements are the truth, and which are fiction? Look for the Truth-or-Fiction items throughout this chapter to find the answers. 1 Most women who contract gonorrhea do not develop symptoms. T / F ? 2 Christopher Columbus brought more than beads, blankets, and tobacco back to Europe from the New World: He also brought syphilis. T / F ? 3 Gonorrhea and syphilis can be contracted from toilet seats in public rest rooms. T / F ? 4 If a syphilitic sore goes away by itself, the infection does not require medical treatment. T / F ? 5 Men can develop vaginal infections. T / F ? 6 As you are reading this, you are engaged in search-and-destroy missions against foreign agents within your body. T / F ? 7 Most people who are infected by HIV remain symptom free and seem to be healthy for years. T / F ? 8 Genital herpes can be transmitted only during flare-ups of the infection. T / F ? 9 Pubic lice are of the same family of animals as crabs. T / F ?
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388 Chapter 14 greater than—the medical consequences. There remains a stigma associated with STIs, rooted in the false belief that they only happen to certain types of people, especially those who some might call “promiscuous.” Many people with STIs worry about the implications of their infections for current and future relationships. The reality is that STIs can happen to anyone who’s sexually active, and they’re very common among Canadians. Becoming knowledgeable about STIs enables us to reduce our risk of infec- tion and deal with any infections that may occur. STIs in Canada LO 14.1 Identify and discuss key features and recent trends in STIs in the Canadian population. Canadian rates vary by STI type. Human papillomavirus (HPV) and genital herpes (herpes simplex virus, or HSV) are the most common. Unfortunately, we don’t have comprehensive national statistics on them, as physicians aren’t required to report cases of these STIs. We’ll discuss the prevalence of HSV and HPV as well as HIV and AIDS later in the chapter. For now, let’s look at some statistics on nationally notifiable (often referred to as “reportable”) bacterial STIs in Canada. Of the STIs for which cases are reported to public health authorities, chlamydia is the most common. There were 116 499 reported cases of chlamydia in 2015 (Public Health Agency of Canada, 2017a). Keep in mind that these numbers reflect only those cases of chlamydia that were diagnosed through testing. Many more cases went unde- tected. Teens and young adults have the highest rates of chlamydia (see Figure 14.1). Chlamydia rates declined between 1992 and 1997 but have since increased. For example, from 1997 to 2015, the reported rate of chlamydia among females aged 20 to 24 years in Canada rose 122%. When we look at the most recent 10-year period for which data are available (2006 to 2015), we see that the reported rate of chlamydia among 20- to 24-year-old females increased by 44%. Figure 14.1 Reported Rates per 100 000 of Chlamydia Among Males and Females Aged 10–14, 15–19, 20–24, 25–29, and 30–39, 2015, Canada. SOURCE: Public Health Agency of Canada. (2017a). Canadian Notifiable Diseases Surveillance System (CNDSS). Retrieved from http://diseases.canada.ca/notifiable/charts?c=abs 0 500 1000 1500 2000 2500 10 to 14 15 to 19 20 to 24 25 to 29 30 to 39 Males Females
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Sexually Transmitted Infections 389 McKay and Barrett (2008) argued that large reported rate increases in chlamydia in Canada over many years were likely attributable, in large part, to more sensitive testing and reporting methods and to increases in the number of people tested for chla- mydia each year. That is, if more people are being tested for chlamydia, and the tests used to detect the infection are more effective, the number of confirmed cases that are reported to public health authorities will increase. The Public Health Agency of Canada in its annual reports on sexually transmitted infections in Canada is careful to note that increases in reported rates of chlamydia, as well as gonorrhea, are likely due to a “vari- ety of factors” in addition to a possible “true rise in incidence” (Public Health Agency of Canada, 2017d, p. 17). That a variety of factors may be contributing to a rise in reported rates of bacterial STIs such as chlamydia and gonorrhea is important to keep in mind as media reports that refer to “rising rates” of STIs often infer inaccurately that these increases are due exclusively to an increase in the prevalence of these infections in the population. Nevertheless, the reported rates of chlamydia indicate that chlamydia is a common infection among Canadian young people. With respect to the age distribution of chlamydia within the population, studies conducted in Western countries have con- sistently found that chlamydia is most common among people under age 25 (Dielissen, Teunissen, & Lagro-Janssen, 2013). As shown in Figure 14.1, reported rates of chlamydia are much higher among females compared to males. However, lower reported rates among males are most likely due to lower rates of testing of males compared to rates of testing among females (Satterwhite & Douglas, 2013). Rates of chlamydia and other STIs vary across Canada. The highest STI rates occur in Nunavut and Northwest Territories, followed by Yukon and Saskatchewan. Over the past decade, Nunavut and Northwest Territories have consistently had the highest rates relative to the other provinces and territories (Public Health Agency of Canada, 2017d). We’ll discuss these differences in the section on social factors and STIs, near the end of the chapter. Gonorrhea is less common than chlamydia. From 2005 to 2014, the reported gonorrhea rate increased by 61.3%, and in 2014, there were 16 289 reported cases (Public Health Agency of Canada, 2017a, 2017d). Like chlamydia, however, only a small proportion of actual cases are diagnosed and reported. For gonorrhea, reported rates among men are highest for those aged 30 to 39, and for females, the highest rates are among those aged 20 to 24 (Public Health Agency of Canada, 2017d). Compared with gonorrhea and chlamydia, the number of syphilis cases is relatively small. Syphilis infec- tion rates decreased in Canada with the introduction of penicillin in the 1940s. In recent years it’s been increasing, however, especially among men who have sex with men. In 2015, 4551 cases of syphilis were diagnosed in Canada, and 87% of those were in men (Public Health Agency of Canada, 2017a). Most of the increase has been due to localized outbreaks in Vancouver, Yukon, Cal- gary, Edmonton, Northwest Territories, Winnipeg, Toronto, Ottawa, Montreal, and Halifax. Who’s at Risk? Adolescents and young adults tend to have shorter relationships than older adults, and therefore more sexual partners. This helps explain why STI rates are highest among young people. Kevin Jordan/Fancy/Age Fotostock
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390 Chapter 14 Researchers at the Public Health Agency of Canada compared STI rates in differ- ent age groups between 1997 and 2007. They found that although rates were still high- est among younger people, rates of chlamydia, gonorrhea, and syphilis were increasing faster among 40- to 59-year-olds (Fang, Oliver, Jayaraman, & Fong, 2010). The researchers suggested that “there is a need for sexual-health information targeting Canada’s middle- aged adults and their health care providers” (Fang et al., 2010, p. 18). These trends appear to be continuing. For example, although the overall reported rate of chlamydia remains much higher in people under age 30 compared to older people, from 2006 to 2015, the reported rate of chlamydia in Canada increased more than twice as much among 40- to 59-year-olds compared to 20- to 24-year-olds (Public Health Agency of Canada, 2017a). Again, we want to emphasize that the actual prevalence of these STIs (in terms of percentage of the population) is much higher than the numbers that make up the reported rates. The reported rates represent only the cases that are officially diagnosed. Bacterial STIs Bacteria cause a range of diseases, such as pneumonia, tuberculosis, meningitis, and the STIs chlamydia, gonorrhea, and syphilis. Chlamydia LO 14.2 Describe the transmission, effects, and treatment of chlamydia. Although some viral STIs are more common, chlamydia is the most common bacterial STI in Canada. Chlamydia infection is caused by the Chlamydia trachomatis bacterium, a parasitic organism that can survive only within cells. This bacterium can cause several types of infection, including non-gonococcal urethritis in males and females, epididy- mitis (infection of the epididymis) in men, and cervicitis (infection of the cervix), endo- metritis (infection of the endometrium), and pelvic inflammatory disease in females (CATIE, 2016a). TRANSMISSION Penile–vaginal and penile–anal intercourse without a condom with an infected partner are the highest-risk sexual behaviours for chlamydia. Chlamydia can be transmitted when a person who has the infection in his or her mouth or throat gives oral sex to another person or when a person gives oral sex to someone who has a genital infection. Oral–anal contact (rimming) and sharing sex toys can also transmit chlamydia. Chlamydia may also cause an eye infection if a person touches his or her eyes after handling the genitals of an infected partner (CATIE, 2016a). SYMPTOMS Chlamydia usually produces symptoms similar to those of gonorrhea, but milder. In men, chlamydia can lead to non-gonococcal urethritis (NGU), an inflamma- tion of the urethra that’s not caused by the gonococcus bacterium. NGU used to be called non-specific urethritis, or NSU. Many organisms can cause NGU, but chlamydia accounts for about half of the cases among men. It causes a thin, whitish discharge from the penis, burning or other pain during urination, soreness in the scrotum, and feelings of heaviness in the testes. These symptoms contrast with the yellow-green discharge and more intense pain produced by gonorrhea. NGU is more prevalent among Ameri- can men than gonorrhea (Hatcher et al., 2011). In women, a chlamydia infection usually occurs in the urethra or cervix. Women may experience burning when they urinate, genital irritation, and a mild vaginal dis- charge. If the infection progresses, women are likely to have pelvic pain and irregular menstrual cycles. The cervix may look swollen and inflamed. Up to 90% of men and 70% of women infected with chlamydia show no symptoms (Centers for Disease Control and Prevention, 2017a). People without symptoms may go untreated and unknowingly pass their infections to their partners. In women, an bacteria A class of single-celled micro-organisms that have no chlorophyll and can give rise to many illnesses. The singular is “bacterium.”
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Sexually Transmitted Infections 391 untreated chlamydial infection can spread throughout the reproductive system, poten- tially leading to pelvic inflammatory disease (PID) and scarring of the fallopian tubes, resulting in infertility (CATIE, 2016a). Untreated chlamydial infections can also damage the internal reproductive organs of men. Chlamydial infections frequently occur together with other STIs, most often gon- orrhea. Nearly half of all cases of gonorrhea involve coexisting chlamydial infections (Hatcher et al., 2011). DIAGNOSIS AND TREATMENT To test for chlamydia, samples are taken from the sites of suspected infection. Testing of urinary and genital tracts may involve provid- ing a urine sample or having a swab of the vagina, cervix, or urethra taken. If there is a discharge from the urethra or vagina, a swab may be taken. For suspected oral or anal infection, a swab of the throat or rectum may be taken (CATIE, 2016a). Antibiotics other than penicillin are highly effective in eradicating chlamydia infec- tions. Penicillin, which is effective in treating gonorrhea, is ineffective against chla- mydia. Treatment of sex partners is critical to preventing the infection from bouncing back and forth (Centers for Disease Control and Prevention, 2017a). Gonorrhea LO 14.3 Describe the transmission, effects, and treatment of gonorrhea. Gonorrhea is the second most commonly reported bacterial STI in Canada. Caused by the Neisseria gonorrhoeae bacterium, it’s characterized by a discharge and burn- ing urination. Left untreated, gonorrhea can cause pelvic inflammatory disease and infertility. TRANSMISSION The gonococcus bacterium requires a warm, moist environment like that found along the mucous membranes of the urinary tract in both genders and the cervix in women. Outside the body, the bacterium dies in about a minute. There’s no evidence that gonorrhea can be picked up from public toilet seats or by touching dry objects. In rare cases, gonorrhea can be contracted by contact with a moist, warm towel or sheet immediately after it’s been used by an infected person. Gonorrhea is nearly always transmitted by unprotected vaginal, oral, or anal sexual activity, or from mother to newborn during delivery. A person who performs fellatio on an infected partner may develop pharyngeal gonorrhea , which produces a throat infection. Mouth-to-mouth kissing and cunnilingus are less likely to spread gonorrhea. A gonorrheal infection may also be spread from the penis to the partner’s rec- tum during anal intercourse. Likewise, a cervical gonorrheal infection can be spread to the rectum if an infected woman and her partner follow vaginal intercourse with anal intercourse. Gonorrhea is less likely to be spread by vaginal discharge than by penile discharge. Gonorrhea is highly contagious. Women stand nearly a 50% chance of contracting gonorrhea after one exposure. Men have a 25% risk of infection (Hatcher et al., 2011). The risks to women are apparently greater because women retain infected semen in the vagina. The risk of infection increases with repeated exposure. SYMPTOMS Some men experience symptoms within two to five days of infection. Symptoms include a penile discharge that’s clear at first and turns yellow to yellow-green, thickens, and becomes pus-like within a day or two. The urethra becomes inflamed, and urination is accompanied by a burning sensation. About 30% to 40% of males have swelling and tenderness in the lymph glands of the groin. The initial symptoms usually abate within a few weeks without treatment, leading people to think gonorrhea is no worse than a bad cold. However, the gonococcus bacterium usually continues to damage the body even if the early symptoms fade. If left untreated, inflammation and other symptoms may become chronic. pelvic inflammatory disease (PID) Inflammation of the pelvic region in women, possibly including the cervix, uterus, fallopian tubes, abdominal cavity, and ovaries. Its symptoms are abdominal pain, tenderness, nausea, fever, and irregular menstrual cycles. The condition may lead to infertility. pharyngeal gonorrhea A gonorrheal infection of the phar- ynx, which is the cavity leading from the mouth and nasal pas- sages to the larynx and esophagus. It’s characterized by a sore throat.
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392 Chapter 14 The primary site of infection in women is the cervix, where gonorrhea causes cervicitis . This results in a yellowish to yellow-green, pus-like discharge that irritates the vulva. If the infection spreads to the urethra, women may also note burning urina- tion. About 80% of women who contract gonorrhea have no symptoms during the early stages of the infection. Because many don’t seek treatment until symptoms develop, they may unknowingly infect other sex partners. 1 ❯ T / F Truth or Fiction Revisited True. Despite the fact that many women who contract gonorrhea experience discharge and some local irritation, it is true that most women who contract gonorrhea do not have noticeable symptoms. About 80% of the women who contract gon- orrhea have no symptoms during the early stages of the infection . Because many infected women do not seek treatment until symptoms develop, they may unintentionally infect another sex partner. When gonorrhea isn’t treated early, it may spread through the urogenital systems in both men and women, striking the internal reproductive organs. In men, it can lead to epididymitis , which can cause fertility problems. Swelling and tenderness or pain in the scrotum are the principal symptoms of epididymitis. Fever may also be present. Occasionally the kidneys are affected. In women, the bacterium can spread through the cervix to the uterus, fallopian tubes, ovaries, and other parts of the abdominal cavity, causing PID. PID symptoms include cramps, abdominal pain and tenderness, cervical tenderness and discharge, irregular menstrual cycles, pain during intercourse, fever, nausea, and vomiting. PID may also occur without symptoms. Whether or not there are symptoms, it can cause scarring that blocks the fallopian tubes, leading to infertility. PID is a serious illness that requires aggressive treatment with antibiotics. Surgery may be needed, to remove infected tissue. Unfortunately, many women become aware of gonococcal infections only when they develop PID. These consequences are all the more unfortunate because gonorrhea, when diag- nosed and treated early, clears up rapidly more than 90% of the time. DIAGNOSIS AND TREATMENT Diagnosis of gonorrhea involves clinical inspection of the genitals by a physician, and culturing and examination of a sample of genital discharge. Antibiotics are the standard treatment. It is recommended that dual therapy with the antibiotics cephalosporin (cefixime or ceftriaxone) and azithromycin be used. Two antibiotics are needed because of the high rates of co-infection with chlamydia and the possibility that some strains of gonorrhea can have resistance to one or more antibiotics. Antibiotic-resistant strains of gonorrhea are an increasing problem. Sex part- ners of people with gonorrhea should be examined (CATIE, 2016c). Syphilis LO 14.4 Describe the transmission, effects, and treatment of syphilis. In 1905, the German scientists Fritz Schaudinn and Erich Hoffmann isolated Treponema pallidum ( T. pallidum ), the bacterium that causes syphilis . Although syphilis isn’t as widespread as it used to be, its effects can be extremely harmful, including heart disease, blindness, gross confusion, and death. 2 ❯ T / F Truth or Fiction Revisited Unclear. It is generally accepted that Columbus exhibited symptoms of advanced syphilis when he died in 1506. However, it is unclear whether or not Columbus brought syphilis back to Europe from the New World. TRANSMISSION Syphilis is most often transmitted by penile–vaginal or penile–anal intercourse or by oral–genital or oral–anal contact with an infected person. The spiro- chete (bacterium) is usually transmitted when an infected person’s open lesions come cervicitis Inflammation of the cervix. epididymitis Inflammation of the epididymis. syphilis An STI caused by the Treponema pallidum bacterium. It may prog- ress through several stages of development, often from a chancre to a skin rash to damage to the cardiovascular or central nervous system.
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Sexually Transmitted Infections 393 into contact with the mucous membranes or skin abrasions of the partner’s body during sexual activity. The chance of contracting syphilis from one sexual contact is estimated at one in three. Syphilis can also be contracted by touching an infectious chancre , but not by using the same toilet seat as an infected person. 3 ❯ T / F Truth or Fiction Revisited False. It is not true that gonorrhea and syphilis can be contracted from toilet seats in public rest rooms. Pregnant women can transmit syphilis to their fetuses, because the spirochete crosses the placental membrane. Miscarriage, stillbirth, or congenital syphilis may result. Congenital syphilis can impair vision and hearing and deform bones and teeth. Blood tests are administered routinely during pregnancy to diagnose syphilis in the mother, so congenital problems can be prevented in the baby. SYMPTOMS Syphilis develops through several stages. In the first stage, or primary stage, two to four weeks after contact, a painless chancre—a hard, round, ulcer-like lesion with raised edges—appears at the infection site. When a woman is infected, the chancre usually forms on the vaginal walls or the cervix. It may also form on the exter- nal genitalia, most often on the labia. When a man is infected, the chancre usually forms on the penile glans. It may also form on the scrotum or the penile shaft. If the mode of transmission is oral sex, the chancre may appear on the lips or tongue. If the infection is spread by anal sex, the chancre may appear in the rectum. The chancre disappears within a few weeks, but if the infection remains untreated, syphilis will continue to work within the body. The secondary stage begins a few weeks to a few months later. A skin rash devel- ops, consisting of painless, reddish, raised bumps that eventually darken and burst, oozing a discharge. Other symptoms include sores in the mouth, painful swelling in the joints, a sore throat, headaches, and fever. A person with syphilis may thus wrongly assume that he or she has the flu. These symptoms also disappear. Syphilis then enters the latent stage, in which it may lie dormant for 1 to 40 years. But spirochetes continue to multiply and burrow into the circulatory system, central nervous system (brain and spinal cord), and bones. The person may no longer be contagious to sex partners after several years, but a pregnant woman can still transmit the infection to her newborn during delivery. 4 ❯ T / F Truth or Fiction Revisited False. The primary and secondary symptoms of syphilis inevitably disappear, but it is not true that the infection does not require medical treatment if a syphilitic chancre (sore) goes away by itself. The belief that medical treatment is unnecessary if the symptoms of an STI disappear by themselves is unfounded. Gonorrhea and syphilis, for example, both can damage the body even when their early symptoms have abated. In many cases, the disease eventually progresses to the late stage, or tertiary stage. A large ulcer may form on the skin, muscle tissue, digestive organs, lungs, liver, and other organs. This destructive ulcer can often be successfully treated, but still more serious damage can occur as the infection attacks the central nervous system or the cardiovascular system (the heart and the major blood vessels). Either outcome can be fatal. The primary and secondary symptoms of syphilis inevitably disappear. Infected people may therefore be tempted to believe they’re no longer at risk, and fail to see their doctors. This is unfortunate, because failure to eradicate the infection through proper treatment can eventually lead to dire consequences. DIAGNOSIS AND TREATMENT Primary-stage syphilis is diagnosed by clinical examination. If a chancre is found, fluid drawn from it can be examined under a micro- scope. The spirochetes are usually quite visible. Blood tests are not definitive until the secondary stage begins. chancre A sore or ulcer. congenital syphilis A syphilis infection that is present at birth.
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394 Chapter 14 Penicillin is the treatment of choice for syphilis, usually a single injection of long-acting benzathine penicillin. People allergic to penicillin can use doxycycline and some other antibiotics. Sex partners of individuals infected with syphilis should be evaluated by physicians (CATIE, 2016d). Vaginal Infections LO 14.5 Describe the transmission, effects, and treatment of vaginal infections. Vaginitis is any kind of vaginal infection or inflammation. Women with vaginitis may encounter genital irritation or itching and burning during urination, but the most com- mon symptom is an odorous discharge. Most cases of vaginitis are caused by organisms that reside in the vagina or by sexually transmitted organisms. Organisms that reside in the vagina may overgrow and cause symptoms when the environmental balance of the vagina is upset by such factors as birth-control pills, antibiotics, dietary changes, excessive douching, nylon underwear, or pantyhose. (See Chapter 3 for suggestions about reducing the risk of vaginitis.) Other cases are caused by sensitivities or allergic reactions to various chemicals. The great majority of vaginal infections involve bacterial vaginosis, candidiasis (commonly called a yeast infection), or trichomoniasis. The microbes that cause vagi- nal infections in women can also infect men’s urethral tracts. A “vaginal infection” can therefore be passed back and forth between sex partners. Bacterial Vaginosis Bacterial vaginosis (BV) is most often caused by overgrowth of the bacterium Gardnerella vaginalis . The bacterium is transmitted primarily through sexual contact. The most characteristic symptom is a thin, foul-smelling vaginal discharge, but infected women often have no symptoms. Diagnosis requires culturing the bacterium in the laboratory. Besides causing troublesome symptoms in some cases, BV may increase the risk of various gynaecological problems, including infections of the reproductive tract. Oral treatments are recommended and effective in most cases. Topical treatments are also effective. Recurrences are common, however. Questions remain about whether the male partner should also be treated. The bac- terium can usually be found in the urethras of symptom-free males. Candidiasis Also known as moniliasis, thrush, or (most often) a yeast infection, candidiasis is caused by a yeast-like fungus called Candida albicans . Candidiasis commonly produces soreness, inflammation, and intense (sometimes maddening!) itching around the vulva, accompanied by a thick, white, curd-like vaginal discharge. Yeast infections can also occur in the mouth in both men and women, and in the penis in men. 5 ❯ T / F Truth or Fiction Revisited Fiction. Biological males cannot literally develop vaginal infections. Only biological females have vaginas. However, not all people who identify as male are biologically male, and furthermore, the pathogens that cause vaginal infections in women may also cause problems for everyone, regardless of sex or gender. Yeast generally produces no symptoms when the vaginal environment is normal. Infections most often arise from changes in the vaginal environment that allow the fungus to overgrow. Antibiotics, birth-control pills, intrauterine devices, pregnancy, and vaginitis Any type of vaginal infection or inflammation. bacterial vaginosis (BV) A form of vaginitis usually caused by the Gardnerella vaginalis bacterium. candidiasis A form of vaginitis caused by a yeast-like fungus called Candida albicans.
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Sexually Transmitted Infections 395 diabetes may alter the vaginal balance, allowing the fungus that causes yeast infections to grow to infectious levels. Nylon underwear and tight, restrictive, poorly ventilated clothing may also set the stage for a yeast infection. Although most cases aren’t the result of sexual transmission, candidiasis can be passed back and forth between sex partners through vaginal intercourse. It can also be passed back and forth between the mouth and the genitals through oral–genital contact, and can infect the anus through anal intercourse. Most infections in women are believed to be caused by an overgrowth of the yeast normally found in the vagina. Still, it’s advisable to evaluate both partners simultaneously. Whereas most men with Candida have no symptoms, some may develop NGU or a genital thrush accompa- nied by itching and burning during urination, or reddening of the penis. Candidiasis can also be transmitted by nonsexual means, such as between women who share a washcloth. Nearly 75% of adult women will experience at least one episode of candidiasis in their lifetimes, and up to 45% of women have recurrent infections (Centers for Disease Control and Prevention, 2015b). Recommended treatments include vaginal supposito- ries or creams, many of which are sold over the counter. Women with vaginal complaints should consult their physicians before taking any of these medications, to ensure that they receive the proper diagnosis and treatment. Trichomoniasis Trichomoniasis (“trich”) is caused by Trichomonas vaginalis , a single-celled parasite. It’s the most common parasitic STI. Symptoms in women include burning or itching in the vulva, mild pain during urination or intercourse, and an odorous, foamy, whitish to yellowish-green discharge. Many women notice that symptoms appear or worsen dur- ing, or just after, their menstrual periods. Trichomoniasis facilitates the transmission of HIV and is linked to the development of tubal adhesions that can result in infertility. Women can be infected with trichomoniasis and have no symptoms. Unlike candidiasis, trichomoniasis is nearly always sexually transmitted. Because the parasite can survive for several hours on moist surfaces outside the body, trich can be communicated via contact with infected semen or vaginal discharge on towels, washcloths, and bedclothes. This parasite is one of the few disease agents that can be picked up from a toilet seat, but the penis or vulva has to directly touch the seat. Trichomonas vaginalis can cause NGU in men, and can cause a slight penile discharge that’s usually noticeable before first urination in the morning. There may be tingling, itching, and other irritating sensations in the urethral tract. Yet most infected men are symptom free. They can therefore unwittingly transfer the organism to their sex partners. Diagnosis is frequently made by microscopic examination of a smear of vaginal fluid in a physician’s office. Diagnosis based on examination of cultures grown from the vaginal smear is considered more reliable, however. When both partners are treated simultaneously, the success rate approaches 100% (Hatcher et al., 2011). Viral STIs LO 14.6 Describe the transmission, effects, and treatment of HIV and AIDS. Viruses are tiny particles of DNA surrounded by protein coatings. They’re incapable of reproducing on their own. When they invade a body cell, however, they can direct the cell’s own reproductive machinery to spin off new viral particles that spread to other cells, causing infection. In this section we’ll discuss several viral STIs: HIV and AIDS, herpes (HSV), viral hepatitis, and human papillomavirus (HPV). HIV AND AIDS Human immunodeficiency virus (HIV) is the virus that causes acquired immunodeficiency syndrome (AIDS) . HIV attacks and disables the immune trichomoniasis A form of vaginitis caused by the protozoan Trichomonas vaginalis. human immunodeficiency virus (HIV) A sexually transmitted virus that destroys white blood cells in the immune system, leaving the body vulnerable to life-threatening diseases. acquired immunodeficiency syndrome (AIDS) A condition caused by the human immunodeficiency virus (HIV) and characterized by destruction of the immune system, stripping the body of its ability to fend off life- threatening diseases.
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396 Chapter 14 system, the body’s natural line of defence, stripping it of its ability to fend off disease- causing organisms. AIDS is considered fatal, although many people now live with HIV indefinitely, thanks to the development of powerful antiviral medications. For people in industrialized nations like Canada, HIV may become a chronic but manageable con- dition, like diabetes. But for many millions in developing nations, where medications are expensive or difficult to deliver, HIV and AIDS may remain a death sentence. Globally, about 36.7 million people were living with HIV in 2016, 1.8 million new infections occurred, and 1 million people died from AIDS-related causes. About 35 million people have died from AIDS-related causes since the epidemic began (UNAIDS, 2017). The majority of people living with HIV live in low- or middle- income countries, particularly in southern and eastern Africa. In many parts of the world (e.g., Africa), most new HIV infections are transmitted through heterosexual sex, but in some countries, men having sex with men and injection drug use are major risk factors. CANADIAN HIV TRENDS According to researchers from the Public Health Agency of Canada from 1985 (when HIV testing began) through December 2016, 84 409 people in Canada were diagnosed with HIV, including those with AIDS (Bourgeois et al., 2017). The reported number of positive HIV tests remained relatively stable between 2002 and 2008, when there were 2619 newly diagnosed cases. The number of diagnosed HIV cases then gradually declined from 2008 to 2014, followed by an increase in 2015 and 2016. In 2016, there were 2344 newly diagnosed and reported cases. The number of people in Canada living with HIV stood at 65 040 at the end of 2014 (Public Health Agency of Canada, 2016). Of these people, it’s estimated that 12 820 (19.7%) were unaware that they had HIV. As shown in Figure 14.2, the proportion of positive HIV test reports among males age 15 or over in Canada in 2016 was highest for the category “men who have sex with men” (MSM), which accounted for over half of cases. Heterosexual contact and injection drug use (IDU) accounted for most of the remaining cases. The exposure category pro- file of women testing positive for HIV in Canada looks quite different than it does for men. As indicated in Figure 14.3, nearly two thirds (64%) of HIV test reports for women in Canada in 2016 were categorized as “heterosexual contact,” and IDU accounted for a little over a quarter (27%). The proportion of new HIV test reports that were among women remained stable at 26% from 2005 to 2008 and decreased slightly to 23% in 2016 (Bourgeois et al., 2017). In 2016, a little less than half of the reported HIV cases with a known race/ethnicity were White (40.4%), followed by Black (21.9%) and Indigenous (21.2%). A significant proportion of the heterosexual HIV infections originate in countries with high HIV prevalence rates, such as those in Africa. CANADIAN AIDS TRENDS Between 1979 and the end of 2016, a total of 24 179 cases of AIDS were reported in Canada (Jonah et al., 2017). The annual number of new AIDS cases reported peaked in 1993 and has declined steadily since then. The primary reason for this decline was the introduction of antiretroviral therapy (ART) in 1996. In 2016, 114 AIDS cases were reported. Among provinces and territories that have continuously reported new AIDS cases (Quebec and several other provinces no longer report on new AIDS cases), the number of new cases has declined by 87% from 1993 to 2016. THE IMMUNE SYSTEM The immune system is the body’s natural line of defence against disease-causing organisms. The immune system combats disease in a number of ways. It produces white blood cells that envelop and kill pathogens such as bacteria, viruses, and fungi, as well as worn-out body cells and cancer cells. White blood cells are referred to as leukocytes . They engage in microscopic war- fare, undertaking search-and-destroy missions to identify and eradicate foreign agents and debilitated cells. Leukocytes recognize foreign agents by their surface immune system The complex of mechanisms the body uses to protect itself from disease-causing agents such as pathogens. pathogen An agent, especially a micro- organism, that can cause disease. leukocytes White blood cells that are essen- tial to the body’s defences against infection.
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Sexually Transmitted Infections 397 fragments, which are called antigens because the body reacts to their presence by developing specialized proteins, or antibodies . Antibodies attach themselves to the foreign agents, inactivate them, and mark them for destruction. HIV infection can therefore be determined by examining blood or saliva for the presence of antibodies to the virus. antigen A protein, toxin, or other sub- stance to which the body reacts by producing antibodies. The word is formed from “antibody generator.” antibody A specialized protein that attaches itself to a foreign body, inactivates it, and marks it for destruction. Figure 14.2 Percentage Distribution of Positive HIV Test Reports Among Males Age 15 and Older by Exposure Category, 2016, Canada. SOURCE: Bourgeois et al. (2017). HIV in Canada—surveillance report, 2016. Canada Communicable Disease Report, 43(12), 248–255. MSM 59% MSM/IDU 5% IDU 11% Heterosexual Contact 22% Other 3% Figure 14.3 Percentage Distribution of Positive HIV Test Reports Among Females Age 15 and Older by Exposure Category, 2016, Canada. SOURCE: Bourgeois et al. (2017). HIV in Canada—surveillance report, 2016. Canada Communicable Disease Report, 43(12), 248–255. IDU 27% Heterosexual Contact 64% Other 9%
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398 Chapter 14 Rather than destroying or marking pathogens for destruction, special memory lymphocytes are held in reserve. Memory lymphocytes can remain in the bloodstream for years, forming the basis for a quick immune response if an invader appears a second time. HIV INFECTION Spikes (technically known as gpl20 spikes) on the sur- face of HIV allow it to bind to sites on cells in the immune system. Like other viruses, HIV uses the cells it invades to spin off copies of itself. HIV uses an enzyme called reverse transcriptase to cause genes in the attacked cells to make proteins the virus needs for reproduction. HIV directly attacks the immune system by invading and destroying a type of lymphocyte called the CD4 cell, or helper T cell (see Figure 14.4). The CD4 cell is the quarterback of the immune system. CD4 cells recognize invading pathogens and signal B lymphocytes, or B cells (another kind of white blood cell), to produce antibodies that inactivate and mark the pathogens for annihilation. CD4 cells also signal another class of T cells, called killer T cells, to destroy infected cells. By attacking and destroying helper T cells, HIV disables the very cells the body relies on for fighting off HIV and other diseases. As HIV cripples the body’s defences, the indi- vidual is exposed to infections that wouldn’t otherwise take hold. Cancer cells might also proliferate. Although the CD4 cells appear to be its main target, HIV also attacks other types of white blood cells. 6 ❯ T / F Truth or Fiction Revisited True. It is true that as you read this, you are engaged in search-and-destroy missions against foreign agents within your body. The white cells in your immune system continuously seek and destroy foreign pathogens within your body. The blood normally contains about 1000 CD4 cells per cubic millimetre. The num- ber of CD4 cells may remain at about this level for years following HIV infection. Many people show no symptoms, appearing healthy, while CD4 cells remain at this level. Then, for reasons that aren’t clearly understood, the CD4 cell level begins to drop off, although symptoms may not appear for a decade or more. As the number of CD4 cells declines, symptoms generally increase, leaving the individual vulnerable to diseases the weakened immune system can’t fight off. A person becomes most vulner- able to opportunistic infections when the level of CD4 cells falls below 200 per cubic millimetre. HIV AND AIDS PROGRESSION HIV follows a complex course once it enters the body. Shortly after infection, the person may experience mild, flu-like symptoms— fatigue, fever, headaches, muscle pain, lack of appetite, nausea, swollen glands, and possibly a rash. These symptoms usually disappear within a few weeks, and the person may dismiss them as a passing case of flu. Once people enter this symptom-free or car- rier state, they generally look and act well, and don’t realize they’re infectious, so they may unwittingly pass the virus to others. Most people who are infected with HIV remain symptom free for years. Some enter a symptomatic state that’s typically marked by chronically swollen lymph nodes and intermittent weight loss, fever, fatigue, and diarrhea. This symptomatic state doesn’t constitute full-blown AIDS, but it shows that HIV is undermining the integrity of the immune system. 7 ❯ T / F Truth or Fiction Revisited True. Most people who are infected with HIV remain symptom free for years. Others enter a symptomatic state that is typically denoted by symptoms such as chronically swollen lymph nodes and intermittent weight loss, fever, fatigue, and diarrhea. This symptomatic state does not constitute full-blown AIDS but shows that HIV is undermining the integrity of the immune system. Figure 14.4 HIV (the AIDS Virus) Attacks a White Blood Cell. HIV progressively weakens the immune system, leaving the body vulnerable to infections and diseases that would otherwise be fended off. Scott Camazine/Science Source
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Sexually Transmitted Infections 399 The beginnings of full-blown AIDS are often marked by such symptoms as swollen lymph nodes, fatigue, fever, night sweats, diarrhea, and weight loss that can’t be attrib- uted to dieting or exercise. AIDS is connected with the appearance of diseases such as pneumonia, Kaposi’s sarcoma (a form of cancer), toxoplasmosis of the brain (an infection by parasites), and herpes simplex with chronic ulcers. These diseases are termed opportunistic diseases , because they’re unlikely to emerge unless a disabled immune system provides the opportunity. About 10% of people with AIDS have a wasting syndrome. Wasting, the uninten- tional loss of more than 10% of a person’s body weight, is connected with AIDS, some other infections, and cancer. As AIDS progresses, the individual grows thinner and more fatigued. The individual becomes unable to perform ordinary life functions and falls prey to opportunistic infections. If left untreated, AIDS nearly always results in death within a few years. TRANSMISSION HIV can be transmitted by certain infected bodily fluids—blood, semen, vaginal secretions, and breast milk. The first three of these may enter the body through vaginal, anal, or oral–genital intercourse with an infected partner. HIV can enter the body through tiny cuts or sores in the mucosal lining of the vagina, the rectum, and even the mouth. These cuts or sores can be so tiny that you’re unaware of them. Penile–anal and penile–vaginal intercourse without a condom are the riskiest sexual behaviours for HIV transmission. HIV transmission during oral sex is possible, espe- cially if a person has sores in the mouth or vagina or on the penis, has bleeding gums, or has oral contact with menstrual blood, or if other STIs are present. Overall, though, according to the U.S. Centers for Disease Control and Prevention (2016), “the chance an HIV-negative person will get HIV from oral sex with an HIV-positive partner is extremely low” (p. e1). Transmission of HIV through kissing— even prolonged or French kissing—is very unlikely. Another avenue of infection is by sharing a hypodermic needle with an infected person. When someone injects drugs, a small amount of his or her blood remains inside the needle and syringe. If the individual is infected with HIV, the virus may be in the blood that remains in the needle and syringe. Others who use the needle inject the infected blood into their bloodstreams. HIV can also be spread by sharing needles used for other purposes, such as injecting steroids, piercing ears, or tattooing. HIV can be transmitted from mother to fetus during pregnancy, or from mother to child through childbirth or breastfeeding. Transmission is most likely during childbirth. Because of ART provided to HIV-positive mothers, the number of babies born HIV infected has been dramatically reduced in Canada. Male-to-female transmission through vaginal intercourse is about twice as likely as female-to-male transmission, partly because more of the virus is found in ejaculate than in vaginal secretions. A man’s ejaculate may also remain for many days in the vagina, providing greater oppor- tunity for infection. Worldwide, male–female sexual intercourse accounts for most HIV and AIDS cases (World Health Organization, 2015b). Male–female and male–male anal intercourse are especially risky, particularly to the recipient, because the rectal tissue often tears or abrades, facilitating the virus’s entry into the bloodstream (Chandra, Bil- lioux, Copen, & Sionean, 2012). DIAGNOSIS There are two main types of HIV testing in Canada: (1) standard HIV testing and (2) rapid point-of-care testing, which is available in some provinces and territories (CATIE, 2017b). In both types, a sample of blood is taken and either sent to a laboratory to be tested opportunistic diseases Diseases that take hold only when the immune system is weakened and unable to fend them off. Can Kissing Transmit HIV? HIV is a blood-borne virus that’s transmitted via various bodily fluids, including blood, semen, and vaginal fluids. The Centers for Disease Control and Prevention (CDC) has found that HIV does not occur in infectious quantities in saliva. GlowImages/Alamy Stock Photo
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400 Chapter 14 for HIV or, in rapid point-of-care testing, tested immediately at the location, often a community-based health centre or sexual health clinic, and the person gets the result right away. With standard testing, the blood is sent to a laboratory, and the person typically returns one to three weeks later to the facility where the blood was taken for the result. With rapid point-of-care HIV testing, if the result of the person’s test indicates that he or she is infected with HIV (also referred to as a “reactive test,” “testing positive,”or “HIV-positive”), a second sample of blood is taken and sent to a laboratory to confirm the diagnosis. In the United States, HIV self-test kits for use at home are available, but they have not been approved for sale by Health Canada. There is a window period between when a person is first infected with HIV and when an HIV test can detect the infection. For the tests used in Canada, the window period for detecting HIV can range from several weeks to more than three months, but for most people, tests can detect HIV within one month of infection (CATIE, 2015). In a 2011 survey, 49% of Canadians aged 16 and older reported that they had been tested for HIV at least once (Calzavara, Allman, Worthington, Tyndall, & Adrien, 2012). In 2014, the government of British Columbia announced it would introduce guide- lines for health care providers to encourage all adults in the province to get tested for HIV. It is hoped that increased availability of rapid point-of-care testing in a wide range of settings will increase the number of people who are tested for HIV in Canada (Minichiello et al., 2017). TREATMENT For many years, researchers were frustrated by their failure to develop effective vaccines and treatments for HIV and AIDS. Work continues on development of a vaccine for HIV, but to date there’s still no safe, effective vaccine. A combination, or “cocktail,” of antiviral drugs has become the standard treat- ment for HIV infection. This combination, referred to as antiretroviral therapy (ART) , slows the rate at which HIV can multiply in the body. The purpose of ART is to reduce the amount of the virus in the body (viral load) to the point that it is no longer detectable by blood tests. ART is not a cure for HIV. However, people with HIV who take ART medications can remain healthy for many years. Thus, the devel- opment of effective ART for people with HIV has been a major breakthrough in the fight against HIV and AIDS, dramatically reducing the number of AIDS-related deaths occurring in Canada. According to the Public Health Agency of Canada (2016), of peo- ple in Canada diagnosed with HIV in 2014, 76% were receiving HIV treatment, and 89% had suppressed HIV viral loads. Research has shown that after a year of ART treatment, over 80% of people with HIV have no detectable virus in their bloodstreams (DeJesus et al., 2012). PREVENTION Not only does ART allow people with HIV to lead longer, healthier lives, but several studies have also demonstrated that ART greatly reduces the likelihood that they will pass the virus to their sex partners (Cohen et al., 2016; Rodger et al., 2016). For example, Rodger et al. (2016) followed for several years 1166 hetero- sexual and gay male couples in which one partner had HIV and was on ART and the other partner did not have HIV. Over the course of the study, the couples reported having sex without condoms about 36 000 times, but there was not a single case of HIV transmission within the couples participating in the study. Although it is clear that ART resulting in HIV viral suppression greatly reduces the risk of HIV transmission, it can’t be concluded, for a number of reasons, that it reduces the risk to zero, and it is recommended that people antiretroviral therapy (ART) A combination of drugs used to treat HIV and AIDS. ART allows people with HIV to live healthy lives and greatly reduces the chances of transmitting HIV to sex partners. Welcome to Condom Country. Condom ads based on the ruggedly masculine Marlboro tobacco ads have been used by the AIDS Committee of Toronto during Pride Week to encour- age gay men to use condoms. Courtesy of AIDS Committee of Toronto
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Sexually Transmitted Infections 401 with HIV who are being successfully treated with ART should still use condoms to protect against HIV and other STIs as well (Daar & Corado, 2016). In addition to the use of ART to reduce the risk of HIV transmission, new develop- ments in HIV prevention include pre-exposure prophylaxis (PrEP) and post-exposure prohylaxis (PEP) . For people who are HIV-negative but are at high risk for HIV infection because of ongoing high-risk sexual behaviour or injection drug use needle sharing, PrEP, which consists of taking Truvada, the medication used for ART, daily, has been shown to be effective in preventing HIV infection (Tan et al., 2017). Similarly, PEP involves tak- ing HIV antiviral medications within 72 hours after an HIV-negative person has been at moderate to high risk of exposure to HIV (e.g., condom breakage, sexual assault). The sooner PEP is started after potential exposure to HIV, the more likely it will effec- tively prevent HIV infection. A person who thinks he or she may have been exposed to HIV should consult a health professional (e.g., an emergency room doctor) as soon as possible. Canadian guidelines suggest that PrEP and PEP should be used as part of a combination HIV-prevention strategy that includes condom use promotion and HIV risk-reduction counselling (Tan et al., 2017). While the addition of ART, PrEP, and PEP to the arsenal of effective HIV- prevention strategies has made a significant contribution to reducing the burden of HIV, it’s necessary for HIV-prevention efforts to continue to empha- size the importance of correct and consistent condom use. Condoms are highly effective in preventing HIV transmission (CATIE, 2017a) and other STIs (Crosby & Bounse, 2012). ART, PrEP, and PEP greatly reduce the risk of HIV, but they do not reduce the risk of other STIs. Most contemporary prevention efforts focus on a combination of ART for people with HIV and education. The success of HIV and AIDS prevention in the develop- ing world depends on access to ART and effective education interventions, access to condoms, and adequate funding for prevention programming. There’s evidence from Africa that male circumcision reduces the risk of HIV acquisition for men. Studies conducted in South Africa, Uganda, and Kenya have found that circumcision reduces HIV infection among heterosexual men by 38% to 66% (Siegfried, Muller, Deeks, & Volmink, 2009). In Canada, HIV- and AIDS-prevention education is often integrated into broader sexual-health education in the schools  (see Chapter 15). Public-health units or agen- cies and community groups also conduct HIV- and AIDS-prevention interventions aimed at higher-risk groups, including men who have sex with men and injection drug users. Herpes (HSV) LO 14.7 Describe the transmission, effects, and treatment of genital herpes. Genital herpes is an STI caused by herpes simplex virus, type 1 (HSV-1) or herpes simplex virus, type 2 (HSV-2) . Although some people with genital HSV infections will never have any visible symptoms, some people will have recurring blister-like sores on the genitals. Herpes is a chronic infection, which means the virus remains in the body for life. HSV-1 usually infects the mouth and is the cause of cold sores on the lips. HSV-1 is a very common infection, affect- ing about half the population (Bradley, Markowitz, Gibson, & McQuillan, 2014). Many people with HSV-1 do not have any symptoms, however. A person with an HSV-1 infection in the pre-exposure prophylaxis (PrEP) The use of HIV antiviral medica- tions by HIV-negative people who are at high risk for HIV infection. post-exposure prohylaxis (PEP) The use of HIV antiviral medi- cations by HIV-negative people within 72 hours after potential exposure to HIV. genital herpes An STI caused by the herpes simplex virus, type 1 (HSV-1) or type 2 (HSV-2). It’s characterized by blister-like sores on the genitals. herpes simplex virus, type 1 (HSV-1) The virus that causes oral herpes, which is characterized by cold sores on the lips and in the mouth. HSV-1 can be transmitted from the mouth of an infected person to the genitals of another person, result- ing in genital herpes. herpes simplex virus, type 2 (HSV-2) A virus that causes many cases of genital herpes. It is usually trans- mitted through genital-to-genital contact. Truvada Truvada, consisting of the antiretroviral drugs tenofovir and emtricitabine, can reduce HIV viral loads to the point where a person with HIV will not transmit the infection during sexual activity. Marc Antoine Saucier/Alamy Stock Photo
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402 Chapter 14 mouth or lips can transmit the virus to another person’s genital area or anus, particu- larly if the person receiving oral sex does not have pre-existing antibodies to HSV-1 from an earlier oral infection (SIECCAN, 2015). It can also be transmitted through genital-to- genital contact, but this is a less common route of HSV-1 transmission (CATIE, 2016b). HSV-2 usually infects the genital area and is most often transmitted by penile–vaginal or penile–anal intercourse. It can be spread from a person’s genitals to another person’s mouth, but HSV-2 infections in the mouth are rare (CATIE, 2016c). Genital herpes is a very common STI—likely much more common than most people assume. Data from the Canadian Health Measures Survey indicated that 13.6% of Canadians aged 14 to 59 have HSV-2 (Rotermann, Langlois, Severini, & Totten, 2013). The prevalence of HSV-2 was higher among women than men (16.1% versus 11%) and lower among Canadians aged 14 to 34 (6.1%) compared to those aged 35 to 49 (19.1%). It’s difficult to determine how common genital herpes caused by HSV-1 is because blood tests to determine if a person has HSV-1 cannot tell where in the body a person has the infection and, as previously noted, many people have an HSV-1 infection in the mouth or on the lips. We do know, however, that an increasing proportion of genital herpes cases, over half among young women in Canada, are caused by HSV-1 (Forward & Lee, 2003; Garceau, Leblanc, Mallett, Girouard, & Thibault, 2012). Most people with genital HSV-1 or HSV-2 infections are asymptomatic—that is, they have no observable signs or symptoms (Garland & Steban, 2014). A study of young women with HSV found that after an initial primary infection, 74% of HSV-1 and 63% of HSV-2 infections were asymptomatic (Bernstein et al., 2013). In the Canadian Health Measures Survey, the vast majority of people with HSV-2 were unaware that they had the virus (Rotermann et al., 2013). People with asymptomatic infections can transmit the virus to others. People with symptoms experience recurrent outbreaks that often happen at the worst times, such as around final exams. This isn’t just bad luck—stress can depress the immune system and heighten the likelihood of an outbreak. Outbreaks can continue to recur, sometimes with annoying frequency. On the other hand, some people have no recurrences. Still others have mild, brief recurrences that become less frequent over time. TRANSMISSION Herpes can be transmitted through oral, anal, or vaginal sexual activity with an infected person. The herpes viruses can also survive for several hours on toilet seats and other objects such as sex toys, where they can be picked up by direct contact. Oral herpes is easily contracted by drinking from the same cup as an infected person, by kissing, and even by sharing towels. But genital herpes is generally spread by penile–vaginal and penile–anal intercourse or by oral sex. Many people don’t realize they’re infected, so they unknowingly transmit the virus through sexual contact. Although genital herpes is most contagious during outbreaks, it can also be transmitted when an infected partner has no symptoms (Garland & Steban, 2014). Any intimate contact with an infected person carries some risk of transmission, even if the infected person never has another outbreak. People may also be infected with the virus and have no outbreaks, yet pass the virus along to others. 8 ❯ T / F Truth or Fiction Revisited Fiction. It is not true that genital herpes can be transmitted only during flare-ups of the infection. Although people are most contagious during flare-ups, genital herpes can also be transmitted between outbreaks. Herpes can be spread from one part of the body to another by touching. One poten- tially serious result is a herpes infection of the eye, called ocular herpes . Thorough washing with soap and water after touching an infected area may reduce the risk of spreading the infection to other parts of the body. The consistent use of condoms reduces the risk of HSV transmission (Stanaway, Wald, Martin, Gottlieb, & Magaret, 2012). However, condoms may not cover all skin ocular herpes A herpes infection of the eye, usually caused by touching an infected area of the body and then touching the eye.
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Sexually Transmitted Infections 403 areas where HSV is present, and this limits the effectiveness of condoms in reducing the risk of transmission. Medications used by people with genital herpes to reduce the severity and frequency of outbreaks can reduce the risk that they will transmit the virus to their sex partners (Corey et al., 2004).Women with genital herpes are more likely to have miscarriages than women in the general population. Passage through the birth canals of infected mothers can infect babies with genital herpes, damaging or killing them. Obstetricians thus often perform Caesarean sections if mothers have active lesions or prodromal symptoms at the time of delivery. SYMPTOMS As noted earlier, most people with genital herpes do not have any observable symptoms. For those who do, genital lesions or sores appear about two to twelve days after infection (Centers for Disease Control and Prevention, 2017b). At first they appear as reddish, painful bumps, or papules, on the penis, vulva, or anus. They may also appear on the thighs or buttocks, in the vagina, or on the cervix. These papules turn into groups of small blisters that are filled with fluid contain- ing infectious viral particles. The blisters are attacked by the body’s immune system (white blood cells). They fill with pus, burst, and become extremely painful, shallow sores (ulcers) surrounded by red rings. People are especially infectious during such outbreaks, because the ulcers shed millions of viral particles. Other symptoms may include headaches and muscle aches, swollen lymph glands, fever, burning urination, and vaginal discharge. The blisters crust over and heal in one to three weeks. Internal sores in the vagina or on the cervix may take 10 days longer than external (labial) sores to heal. Although the symptoms disappear, the infection doesn’t. The virus remains in the body permanently, burrowing into nerve cells in the base of the spine, where it may lie dormant for years or for a lifetime. For reasons that remain unclear, in most cases the virus becomes reactivated and gives rise to recurrences. Recurrences may be related to infections (such as a cold), stress, fatigue, depression, exposure to the sun, and hormonal changes such as those that occur during pregnancy or menstruation. Recurrences tend to occur within 3 to 12 months of the initial episode, and affect the same parts of the body. The symptoms of oral herpes include sores and blisters on the lips, inside the mouth, on the tongue, and in the throat. The person may experience fever and feelings of illness, as well as swollen, reddened gums. The sores heal over in about two weeks, and the virus retreats into nerve cells at the base of the neck, where it lies dormant between flare-ups. DIAGNOSIS AND TREATMENT Genital herpes is first diagnosed by clinical inspec- tion of herpetic sores or ulcers in the mouth or on the genitals. A sample of fluid may be taken from the base of a genital sore, and cultured in the laboratory, to detect the growth of the virus. Medical treatments for genital herpes can reduce symptoms but are not a cure. The Public Health Agency of Canada (2013) recommends that treatment for a first outbreak be started as soon as possible after symptoms appear. Antiviral medications prescribed by a doctor to treat genital herpes include acyclovir, valacyclovir, and famciclovir. These medications can be used to reduce the severity and duration of recurrent outbreaks and should be taken as soon as symptoms begin to appear. People who have frequent recur- rences (i.e., six or more outbreaks a year) can be prescribed antiviral medications to be taken on a daily basis (referred to as suppressive therapy). Warm baths, loosely fitting clothing, aspirin, and cold, wet compresses may relieve pain during flare-ups. People with herpes are advised to maintain regular sleeping habits and learn to manage stress. There’s no safe, effective vaccine for genital herpes, but clinical trials of experi- mental vaccines are underway (American Osteopathic College of Dermatology, 2015). COPING WITH GENITAL HERPES The psychological impact of herpes can be more distressing than its physical effects. The prospect of recurrences and concern about infecting sex partners exacerbate the emotional impact of herpes. However, most people prodromal symptoms Warning symptoms that signal the onset or flare-up of a disease.
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404 Chapter 14 with herpes learn to cope with the infection, and with adjustments, are able to establish and maintain satisfying intimate relationships. Some are helped by support groups that share ways to live with the infection. Many people with genital herpes find it difficult to talk with partners about the infection. Whether it is informing a current partner after a person has received a genital herpes diagnosis or talking to a new partner, there are a number of ways to prepare for these discussions: • Learn the facts about HSV (symptoms, treatment, testing, and prevention). • Pick a time that is nonsexual and not rushed. • Pick a place that is private, nonsexual, neutral, and quiet. • Prepare yourself; use all the resources you can find. • Ask for help from a health care provider. • Give your partner websites to view. • Be calm and avoid negative words. • Be realistic and remember that your partner may have some of the same feelings you did and will need time to process the information you have given (Sexual health issue brief, SIECCAN, 2015). The attitudes of people with herpes affect their success in adjusting to it. People who view herpes as a manageable condition, not as a medical disaster or a character deficit, find it easier to adjust (see Innovative Canadian Research: Living with STI: Resisting STI-Associated Stigma). Viral Hepatitis LO 14.8 Describe the transmission, effects, and treatment of viral hepatitis. Hepatitis is an inflammation of the liver that may be caused by such factors as chronic alcoholism and exposure to toxic substances. Viral hepatitis includes several types of hepatitis caused by related but distinct viruses. The major types are hepatitis A, hepa- titis B, hepatitis C, and hepatitis D. Most people with acute hepatitis have no symptoms. When symptoms do appear, they often include jaundice , feelings of weakness and nausea, loss of appetite, abdomi- nal discomfort, whitish bowel movements, and brownish or tea-coloured urine. The hepatitis An inflammation of the liver. jaundice A yellowish discoloration of the skin and the whites of the eyes. INNOVATIVE CANADIAN RESEARCH LIVING WITH STI: RESISTING STI-ASSOCIATED STIGMA Although STIs are extremely common and can affect any person who is sexually active, there is significant stigma associated with STIs. Individuals with STIs are often unfairly stereotyped with labels such as “slut,” “dirty,” or “promiscuous,” and it is there- fore not surprising that many people with STIs report a variety of negative emotions, including anxiety, embarrassment, guilt, shame, depression, and a lower sexual self-concept (Foster & Byers, 2013). In order to avoid STI-associated stigma, some people may avoid getting tested for STIs. A study by Lyndsay Foster and Sandra Byers (2016) from the University of New Brunswick examined sexual well- being in 188 individuals, with an average age of 36, who had been living with either genital herpes or HPV for an average of seven years. Study participants completed measures of sexual activity, sexual problems, and sexual cognitive-affective factors. The vast majority of participants reported very few sexual prob- lems due to their STI diagnosis. Participants reported high lev- els of sexual satisfaction, high levels of sexual self-esteem, and positive sexual self-schemas. The participants also reported engaging in sexual activity on a regular basis and reported little anxiety in sexual situations. People who internalized the stigma associated with their STI diagnosis, as measured by the STI Stigma Scale (“Only people who have slept around get STIs”; “Someone with an STI is damaged goods”) reported the poorest sexual well-being. According to Foster and Byers (2013), sexual-health educa- tion should emphasize that all people who have sex can contract STIs, including people who are trying to be responsible with their sexual behaviour, and that this may help to separate STIs from negative stereotypes.
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Sexually Transmitted Infections 405 symptoms of hepatitis B tend to be more severe and long-lasting than those of hepatitis A or C. In about 10% of cases, hepatitis B leads to chronic liver disease. Hepatitis C tends to have milder symptoms, but often leads to chronic liver diseases such as cirrhosis and cancer of the liver. Hepatitis D occurs only in the presence of hepatitis B. It has symp- toms similar to those of hepatitis B, can produce severe liver damage, and often leads to death. The hepatitis A virus is transmitted through contact with infected fecal matter in contaminated food or water, and by oral contact with fecal matter, such as through oral–anal sexual activity (licking or mouthing the partner’s anus). It’s largely because of the risk of hepatitis A that restaurant employees are required to wash their hands after using the toilet. Ingesting uncooked infested shellfish is also a frequent means of transmission for hepatitis A. Hepatitis B can be transmitted through penile–vaginal, penile–anal intercourse or oral sex with an infected partner; transfusion with contaminated blood supplies; shar- ing of contaminated needles or syringes; and contact with contaminated saliva, men- strual blood, nasal mucus, or semen. Sharing razors, toothbrushes, and other personal articles with an infected person can also transmit hepatitis B. Hepatitis C and hepatitis D can be transmitted sexually or through contact with con- taminated blood. Hepatitis D can occur only if hepatitis B is present. People can transmit the viruses that cause hepatitis even if they’re unaware that they have the disease. In Canada, infection rates for hepatitis A and B declined significantly during the 1990s. Since then, rates of hepatitis A, B, and C have all steadily declined (Centers for Disease Control and Prevention, 2017c; Public Health Agency of Canada, 2017c) Hepatitis is usually diagnosed by testing blood samples for the presence of hepa- titis antigens and antibodies. Bed rest and fluids are usually recommended until the acute stage of the infection subsides, generally in a few weeks. Full recovery may take months. A vaccine provides protection against hepatitis B and D. Fortunately, new treat- ments that can cure most people with hepatitis C are now available (CATIE, 2017c). Human Papillomavirus (HPV) LO 14.9 Describe the transmission, effects, and treatment of human papillomavirus. HPV is the most common STI in Canada and around the world. It’s estimated that more than 70% of adult Canadians will have at least one HPV infection in their lifetimes (Public Health Agency of Canada, 2017b). Studies of university students in Canada have reported HPV rates of 29% to 50% (Burchell, Tellier, Hanley, Coutlée, & Franco, 2010; Richardson et al., 2003). Most HPV infections are asymptomatic and harmless. In up to 90% of cases, the body’s immune system clears up the infection within two years (Gargano, Meites, Watson, Unger, & Markowitz, 2017). There are many different subtypes of HPV. Some, such as types 6 and 11, cause genital warts . Others, such as types 16 and 18, which don’t cause genital warts, can eventually lead to different types of cancer if they persist undetected for a number of years. In women, HPV infections are responsible for nearly all cervical cancers and a majority of cancers of the anus, vulva, and vagina, as well as head and neck cancers. In men, HPV infections are responsible for the majority of anal, penile, oropharyngeal (throat), and oral cavity cancers (National Advisory Committee on Immunization, 2016). It bears repeating that HPV infection is extremely common, usually resolves on its own, and only in rare instances progresses to cancer. In most cases, the cancer can be effectively treated, especially if it’s detected early. TRANSMISSION Penile–vaginal intercourse, penile–anal intercourse, and oral sex are the most common means of HPV transmission. Other types of skin-to-skin contact with infected areas can transmit HPV. genital warts An STI caused by the human papillomavirus. It takes the form of warts around the genitals and anus.
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406 Chapter 14 Because HPV is so common, reducing the risk of infection is difficult, especially for people who are sexually active. Abstaining from sexual activity is clearly one way a per- son can avoid HPV infection. While condoms cannot protect against transmission of HPV to and from genital areas not covered by a condom, studies have indicated that consistent condom use reduces the risk of HPV infection (Hariri & Warner, 2013; Winer et al., 2006). Some types of HPV can result in genital warts, which vary in size and shape. Genital warts can be hard and yellow-grey when they form on dry skin, or they can take on a pink, soft, cauliflower appearance in moist areas such as the lower vagina. In men, they appear on the penis, foreskin, and scrotum and in the urethra. In women, they appear on the vulva, along the vaginal wall, and on the cervix. They can also occur outside the genital area—for example, in the mouth; on the lips, eyelids, or nipples; around the anus; and in the rectum. The incubation period from time of infection to appearance of the warts can range from a few weeks to more than a year. DIAGNOSIS AND TREATMENT Genital warts are diagnosed through visual inspec- tion by a health care professional. Pap tests are used to detect precancerous changes to the cervix that are caused by HPV, and DNA tests are also sometimes used. Various screening tests and detection techniques are used to detect other forms of HPV-related cancers. HPV- related cancers are typically treated with chemotherapy, surgery, or radiation therapy. There are several treatments for genital warts. Cryotherapy, or freezing the warts with liquid nitrogen, is a preferred treatment. Another treatment involves painting or coating the warts over several days with an alcohol-based podophyllin solution, gel, or cream, which causes the warts to dry up and fall off. The warts can also be treated by a doctor, who may burn them off with electrodes or remove them by laser or conventional surgery. Unfortunately, removing the warts doesn’t rid the body of the virus, and there may be recurrences. Eventually, the warts will clear up. People with active warts should probably avoid sexual contact until the warts are removed and the area heals completely. VACCINE A major advance in the fight against STIs has been the development of a vaccine that immunizes against the HPV types that cause genital warts and those that cause the majority of HPV-related cancers. Canada’s National Advisory Committee on Immunization (2016) recommends HPV vaccination for females and males from the ages of 9 to 26 years and notes that the vaccine can also be used in people older than age 26. It’s expected that as more and more people, especially youth, are vaccinated against HPV, the incidence of genital warts and HPV-related cancers will decline. All provinces and territories in Canada have implemented publicly funded school vaccine programs, but acceptance of the HPV vaccine hasn’t been universal. Some have questioned whether a large-scale HPV vaccination program is appropriate, given that cervical cancer is relatively rare in Canada and Pap tests are an effective method of screening (Lippman, Melnychuck, Shimanin, & Boscoe, 2007), although it should be noted that other forms of HPV-related cancers, such as oropharyngeal cancer, are on Real Students, Real Questions Q Do some infections just naturally go away? A Absolutely. In many cases, your immune system does clear some of the STIs, and, fortunately, HPV and Zika are a couple of these. But check routinely with your physician if you have had an HPV infection. Unfor- tunately, some of the worst infections, including HIV, do not disappear permanently on their own, even if they lie dormant for years. RubberBall/Alamy Stock Photo
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Sexually Transmitted Infections 407 the rise. Some parents and religious groups have opposed the vaccine, fearing that it might encourage promiscuity. However, research has found that youth who receive the HPV vaccine are not more likely to be sexually active than youth who don’t receive it (Madhivanan et al., 2016; Smith, Kaufman, Strumpf, & Lévesque, 2015). Ectoparasitic Infestations LO 14.10 Describe the transmission, effects, and treatment of ectoparasitic infestations. Ectoparasites live on the outer surfaces of animals. They’re larger than the agents that cause other STIs. In this section, we’ll consider two types of STIs caused by ectoparasites—pediculosis and scabies. Pediculosis Pediculosis is the name given to an infestation of a parasite whose proper Latin name, Pthirus pubis , sounds rather too dignified for these bothersome creatures. Their common name is pubic lice, but they’re commonly called crabs, because that’s what they look like under the microscope. 9 ❯ T / F Truth or Fiction Revisited Fiction. It is not true that pubic lice are of the same family of animals as crabs, but when viewed under a microscope, pubic lice look similar to crabs. Pubic lice actually belong to a family of insects called “biting lice.” Another member of the family, the human head louse, is an annoying insect that clings to hair on the scalp and often spreads among schoolchildren. In the adult stage, pubic lice are large enough to be seen with the naked eye. They’re spread sexually, and can also be transmitted via contact with infested towels, sheets, and—yes—toilet seats. They can survive for only about 24 hours without a human host, but they may deposit eggs that can take up to seven days to hatch in bedding and towels. All bedding, towels, and clothes that have been used by an infested person must be dry cleaned or washed in hot water and dried on the hot cycle, to ensure that they’re safe. Fingers may also transmit the lice from the genitals to other hair-covered parts of the body, including the scalp and armpits. Sexual contact should be avoided until the infestation is eradicated. Itching that ranges from mildly irritating to intolerable is the most prominent symptom of an infestation of pubic lice. The itching is caused by the crabs’ attaching themselves to the pubic hair and piercing the skin to feed on the blood of their hosts. An infestation can be effectively treated with medication. ectoparasite A parasite that lives on the outer surface of an animal. pediculosis An infestation of pubic lice. Real Students, Real Questions Q Can you get “crabs” if you are shaved? A Probably not in those areas that are shaved. They attach to the base of pubic hairs (or other hairs) and bite through the skin from there so they can feed on blood. Artpose Adam Borkowski/Shutterstock
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408 Chapter 14 Scabies Scabies ( Sarcoptes scabiei ) is a parasitic infestation by a tiny mite that may be transmitted through sexual contact or contact with infested clothing, bed linens, towels, and other fabrics. The mites attach themselves to the base of the pubic hair and burrow into the skin, where they lay eggs and subsist for the duration of their 30-day life spans. Like pubic lice, scabies are often found in the genital region, where they cause itch- ing and discomfort. They’re responsible for reddish lines (created by burrowing), sores, welts, and blisters on the skin. Unlike lice, they’re too tiny to be seen with the naked eye. Diagnosis is made by detecting the mite or its by-products via microscopic examination of scrapings from suspicious-looking areas of skin. Scabies are most often found on the hands and wrists, but they may also appear on the genitals, buttocks, armpits, and feet. Scabies, like pubic lice, can be effectively treated with medication. To avoid reinfec- tion, sex partners and others in close bodily contact with infected individuals should also be treated. Clothing and bed linens used by an infested person must be dry cleaned or washed and dried on the hot cycle. Sexual contact should be avoided until the infes- tation is eliminated. STI Epidemiology: Biological, Psychological, and Social Factors LO 14.11 Identify and assess the roles of different biological, psychological, and social factors in the epidemiology of STIs in Canada. Despite advances in medical knowledge about the biology of STIs and HIV and AIDS, and extensive research on how they spread through the population, these infections are still common in Canada and around the world. Why? One obvious answer is that too many people are unaware of their own personal risks for STIs and HIV, and therefore engage in high-risk behaviours. At a basic level, this is undoubtedly true. Many people lack a basic knowledge of STIs and HIV, and are unaware that they’re at risk. To fully understand why it’s so difficult to eliminate these infections, however, we need to examine several important factors that drive the spread of STIs and HIV. At the beginning of this book, we emphasized the importance of a multidisciplinary approach to understanding human sexuality. You may recall that we need to account for the biological, psychological, and social factors that shape our sexuality. This multi- disciplinary approach helps us more fully understand how STIs and HIV spread within the population. Biological Factors MULTIPLE MEANS OF TRANSMISSION STIs and HIV can be transmitted in multiple ways. These include high-risk sexual behaviours, such as unprotected penile–vaginal and penile–anal intercourse. Oral sex is another form of potential transmission. For STIs such as herpes and the human papillomavirus, transmission can occur through skin-to-skin contact with an infected area. STIs and HIV can also be spread in nonsexual ways. Sharing contaminated needles for injecting drugs is one of the most common ways of transmitting HIV. Using contaminated needles for tattooing can also transmit HIV and hepatitis. Some infections, such as HIV and HSV, can be transmitted from an infected mother to her infant, in the womb or during birth. LIFELONG INFECTIONS Among the most effective ways to reduce the spread of STIs and HIV are effective treatments and cures. Although medical science has made progress in developing treatments, some viral infections are lifelong. Once a person has been infected with HSV, for example, the virus will stay in the body for life. scabies A parasitic infestation by a tiny mite that may be transmitted through sexual contact or contact with infested fabrics.
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Sexually Transmitted Infections 409 There are now more effective treatments to manage the symptoms, and in some cases to reduce the chances of transmitting these infections. But because they can’t be cured, it’s more difficult to control the spread of these infections in the population. ASYMPTOMATIC CASES Many people who become infected with STIs have no observable symptoms. These cases are referred to as asymptomatic. The symptoms may never show up, or there may be time lags between the infections and the appear- ance of symptoms. Because many are asymptomatic, people with HIV, HSV, HPV, chlamydia, and other STIs often don’t know they’re infected. These people are unlikely to get treatment or take preventive measures, such as using condoms. This is a key biological factor that facilitates the spread of these infections. INCREASED VULNERABILITY STIs that produce genital ulcers, such as syphilis and genital herpes, heighten vulnerability to HIV infection by allowing other viruses to enter the circulatory system through the ulcers. Some STIs, such as gonorrhea, tricho- moniasis, and chlamydia, can inflame the genital region, which heightens the risk of sexual transmission of other STIs. GENDER Women are more susceptible to STI infection than men. The warm, moist environment of the vagina is more hospitable to bacteria, viruses, and fungi than is the exterior of the penis. The location of the urethra and bladder in women also makes them more susceptible to infection. LACK OF VACCINES AND CURES It has been very difficult to develop vaccines to pre- vent STIs. The HIV virus has been especially resistant to vaccines. Fortunately, an effec- tive vaccine has recently been developed that prevents many strains of HPV. There’s also a vaccine being developed that appears to be successful in preventing herpes infections. Psychological Factors A number of psychological factors predict sexual risk-taking. These include perceived low risks of infection, the myth of personal invulnerability, lack of awareness of a partner’s infection, negative attitudes toward condoms, drug and alcohol abuse, and difficulty discussing sexual-health issues. PERCEIVED LOW RISK One of the major stumbling blocks in promoting safer-sex practices such as condom use is the fact that many people perceive themselves at low risk for contracting STIs and HIV. For example, Langille and Steenbeek (2013) at Dalhousie University conducted an online survey and found only 14% of Halifax university stu- dents with two to five sex partners in the previous year and who did not use a condom at last intercourse rated themselves as being at high risk. In a study of over 10 000 young adults in the United States, of those with a current or recent bacterial STI, 71% indicated that they were at low risk for STI (Kaestle & Waller, 2011). Research has suggested that many youth and young adults significantly underestimate their risk for STI and, as a result, do not prioritize consistent condom use (Pollack, Boyer, & Weinstein, 2013). Gay men may also operate under an “I’m not the type” fallacy, underestimating their personal risks. In a survey of men who have sex with men across Canada, although 75% of the men reported that they had been tested for HIV, 74% of those who had never had an HIV test said it was because they believed they were at low risk of infection (Myers et al., 2013). LACK OF COMMUNICATION Many people are embarrassed about asking partners about their past risk behaviours and their STI or HIV status. And people who have engaged in high-risk behaviours or contracted STIs or HIV may be uncomfortable about revealing this information, because they fear their partners will refuse to have sex or end the relationships. In other cases, people may not feel empowered enough in their relationships to assertively communicate about the need to practise safer sex.
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410 Chapter 14 Promoting and facilitating an increased level of sexual communication and condom use negotiation skills can be an important element of effective STI/HIV prevention programs (Sales et al., 2012). An ongoing issue is the question of whether people with HIV have a legal obligation to inform their sexual partners of their status before having sex. According to Canadian law, people living with HIV have a duty to disclose their HIV status before engaging in sexual behaviours that pose a “realistic possibility” of transmitting HIV to another person. Up to the end of 2016, at least 184 people who had allegedly failed to disclose their HIV status had been charged with criminal offences in Canada (CATIE, 2017d). The effective- ness of ART in significantly reducing HIV viral loads and thereby reducing the chances that a person with HIV will transmit the virus during sexual activity has had an impact on the discussion of the appropriateness of the current laws. At present, people with HIV are required to inform their partners of their HIV status if a condom is not used, no matter how low their viral load is. However, it’s legally unclear at present whether individuals who have an undetectable HIV viral load and use condoms are legally required to disclose their HIV status to their sex partners. As a result, criminal charges continue to be brought against people with HIV who do not disclose their HIV status, even though they are on ART and maintain an undetectable viral load (CATIE, 2017d). Some have argued that criminally prosecuting people who knowingly transmit HIV is a valid deterrent that holds people with HIV responsible for their behaviour (Berger, 2009). However, others contend that there is no evidence that the criminaliza- tion approach is effective in reducing new HIV infections and that the fear of criminal prosecution may deter people from getting tested for HIV (CATIE, 2017d). From this perspective, HIV-prevention education and risk-reduction counselling may be more effective than criminalization in changing complex human behaviours related to sexu- ality and drug use. PSYCHOLOGICAL OBSTACLES TO CONDOM USE Effectively promoting the consistent use of latex condoms may be the most important factor in reducing the bur- den of STIs and HIV in Canada. Yet many Canadians who are at risk don’t use condoms. A national survey found that condoms are the most popular method of contracep- tion among Canadian women, especially younger women (Black et al., 2009). When the survey was taken, 74.3% of 15- to 19-year-olds, 55.5% of 20- to 29-year-olds, 48.8% of 30- to 39-year-olds, and 42.5% of women over 40 who’d had vaginal intercourse in the previous six months said they’d used condoms for contraception. Notice that the percentage of people who use condoms declines with age; sexually active teens are those most likely to use condoms. Analyzing data from the Canadian Community Health Survey, Rotermann and McKay (2009) found that among unmarried, non-cohabiting 20- to 34-year-old Canadians, 35.8% had had more than one intercourse partner during the previous 12 months, while about 30% of the males and nearly 40% of the females who’d had three or four partners during the previous year hadn’t used condoms at last intercourse. There are a number of explanations for why Canadians at risk for STIs and HIV don’t use condoms. Some we’ve already discussed, such as perceived low risk for infection. As adolescents get older and form longer-term relationships, some switch from condoms to the pill. Although birth-control pills are reliable methods of contraception, they don’t prevent STIs. After examining data from the Canadian Contraception Study, (Fisher et al., 2004) concluded that many young women were using the condom first and foremost as a method of birth control, not as a method of STI/HIV prevention, and were therefore unconcerned about switching to the pill. In many cases, this also speaks to their low perceived risk for infection. A more recent study of Canadian university students confirms that decision-making related to condom use or nonuse tends to be related to contraception rather than STIs (Milhausen et al., 2013).
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Sexually Transmitted Infections 411 Researchers at Okanagan University College in British Columbia have found that young people in monogamous relationships don’t use condoms because they’re in love and trust their partners to be faithful (Netting & Burnett, 2004). In the Canadian Con- traception Study, 47% of the women who’d reduced or discontinued their condom use gave the reason “I have only one sexual partner,” and 46% said “I know and trust my husband or partner” (Fisher et al., 2004a). While many of these women may have been correct in their assessments, if their known, trusted partners had unknown asymptom- atic STIs or HIV infections from previous relationships, their discontinuation of condom use resulted in high risks for infection. It has also been found that the more in love a woman is with her partner, the more strongly she believes she’s not at risk for getting an STI from him (Knäuper, Aydin, Atkinson, Guberman, & Kornik, 2002). Rupert Klein and Bärbel Knäuper (2002) at McGill University have found that female university students believe condom use signifies lack of commitment and trust in their relationships. These studies, and many others, indicate that one of the most significant obstacles to condom use involves the dynamics of a couple relationship. Other obstacles to condom use are more practical. Some people, including uni- versity students, feel embarrassed about buying them (Ronis & LeBouthillier, 2013). Some feel that interrupting the sexual act to apply a condom reduces spontaneity. Some men and women say condoms reduce sexual pleasure. In an Ontario study (Adam, Husbands, Murray, & Maxwell, 2005), gay and bisexual men gave the following reasons for not using condoms: • Fear of erection loss • Urgency of passion overcoming fear of infection • Stress and depression overcoming rational prevention • Low self-esteem, leading to indifference about consequences • Reliance on intuition to determine whether a partner is HIV negative • Development of a trusting relationship with a partner Unless such obstacles to using condoms are overcome, efforts to stem the tide of STIs infection may be thwarted (see Applied Knowledge: Reducing Your Risk for STIs). ALCOHOL AND DRUG USE There is substantial evidence linking alcohol consump- tion and illicit drug use to elevated risk for STI. A number of studies have found an association between problematic levels of alcohol consumption (e.g., binge drinking) and STI (Cook & Clark, 2005). A study of women aged 18 to 29 found that alcohol consumption predicted the likelihood of STI diagnosis (Seth, Wingood, DiClemente, & Robinson, 2011), and another study of STI clinic patients found that binge-drinking women were five times more likely to be diagnosed with gonorrhea than abstainers (Hutton, McCaul, Santora, & Erbelding, 2008). The degree to which illicit drug use is associated with STI is dependent on a number of factors including the drug in question and the level of use. An analysis of data from the U.S. Youth Risk Behavior Survey found an association between unprotected sex and illicit drug use (Anderson & Mueller, 2008). Research with young Indigenous people in British Columbia who used drugs found high levels of unprotected sex (Chavoshi et al., 2012). A review of the literature by the Public Health Agency of Canada (2012d) con- cluded that drug use (e.g., amphetamines, ecstasy, poppers, cocaine, opiates) is linked to risk-taking during sexual encounters. Many other psychological factors can account for sexual risk-taking. Barry Adam (2006) at the University of Windsor has taken a broader perspective by critiquing some health educators’ contention that rational decision making should result in avoidance of risky sexual behaviours. He argued that the drive to satisfy certain emotional needs
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412 Chapter 14 can often override longer-range safety concerns. For example, someone who is less attractive, less secure, or more needy than his or her partner may not insist on condom use, for fear of losing the partner. And someone who believes true sexual intimacy involves ejaculation without a condom may feel emotionally and sexually unfulfilled if a condom is used. Social Factors STI rates are linked to a number of social factors such as socioeconomic status, social capital, gender inequality, sexual orientation, ethnocultural factors, and negative soci- etal attitudes toward STI-infected people. SOCIOECONOMIC STATUS Socioeconomic status (SES) (e.g., level of income, education, employment) is one of the strongest predictors of health, including risk for STI (Public Health Agency of Canada, 2014a; 2015). Some studies have found a direct association between SES and STI prevalence. For example, a large-sample study in the United States found an association between both income and racial/ethnic identity and prevalence of bacterial STIs (Harling et al., 2013). Bush et al. (Bush, Henderson, Dunn, Read, & Singh, 2008) found that lower SES (income, education) census tracts in the Calgary Health Region had a higher prevalence of chlamydia than higher SES tracts. In a similar study of census tracts in the city of Toronto, Hardwick and Patychuk (1999) found an association between low income and chlamydia among 15- to 24-year-olds. A high level of STI prevalence was also found among street youth in Ottawa (Shields et al., 2004). Young women who have low incomes or who live below the poverty line may be at greater risk for contracting STIs through participation in survival sex as a source of income (Public Health Agency of Canada, 2015). SOCIAL CAPITAL University of Windsor researchers (Smylie, Medaglia, & Maticka-Tyndale, 2006) have found that Canadian youth with strong social ties to family, peers, and community organizations are less likely to engage in risky sexual behaviours than youth without these strong ties. Their social networks provide intangible resources that enable them to make healthier decisions, resulting in fewer social problems for themselves and for society. In a study of adolescents in Nova Scotia, Langille et al. (2014) found that lower levels of school connectedness, which can be a salient form of social capital for youth, were associated with having two or more sex partners in the previous year and not using a condom at last intercourse for boys but not girls. The results of both of these studies suggest that social capital factors may play a stronger role in shaping STI risk behaviour among male youth compared to female youth. GENDER INEQUALITY As we discussed in Chapter 5, stereotypical gender roles for men and women include sexual behaviour within relationships. The traditional sexual script, for example, provides men with relatively more control over sexual behaviour and, as a result, places women in a disadvantaged position in negotiating condom use. Thus, women who have low levels of power within their romantic/sexual relationships with men are more likely to be at high risk for STI than women in more egalitarian relationships (Public Health Agency of Canada, 2015). A study of young women aged 15 to 21 found that those who perceived themselves to have less power in their relationship were almost four times as likely to have an STI than those who perceived themselves to have more relationship power (Raiford, Seth, & DiClemente, 2013). Research on youth in Canada found that girls—but not boys—who’d been pressured to have sex were less likely to use condoms than girls who’d had sex without being pressured (Gallupe, Boyce, & Fergus, 2009). A Toronto study found that young fathers with higher gender equitable attitudes were more likely to use condoms with their partners than those with lower scores on a gender equity scale (Nelson, Thach, & Zhang, 2014).
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Sexually Transmitted Infections 413 Experiencing intimate partner violence (i.e., physical, sexual, verbal/psychological harm) is associated with increased odds of contracting an STI. For example, results from a large-sample U.S. study found that being involved in a verbally abusive relationship was associated with not using a condom at last intercourse among female teenagers (Roberts, Auinger, & Klein, 2005). A number of studies have shown that women who are victims of intimate partner violence have a higher prevalence of STI than women in nonviolent relationships (Coker, 2007; Hess et al., 2012). Trans women face multiple barriers to accessing health services due to experi- ences of discrimination and a fear of being judged. These barriers can contribute to their marginalization and increase their vulnerability to STI (Public Health Agency of Canada, 2015). SEXUAL ORIENTATION An international study of adolescents in Canada, New Zealand, and the United States has revealed that lesbian, gay, and bisexual (LGB) youth are more likely than heterosexuals to engage in behaviours that pose high risk for HIV (Meininger et al., 2007). In all three countries, LGB youth experience more discrimination and stigmati- zation than heterosexual youth. In the Canadian and American samples, this stigmatization has a significant influence on risk-taking, regardless of sexual orientation. The researchers have concluded that reducing discrimination against LGB youth may reduce sexual risk- taking among this age group (see Innovative Canadian Research: The Male Call Canada Survey of Men Who Have Sex With Men). APPLIED KNOWLEDGE REDUCING YOUR RISKS FOR STI S STIs are very common, especially among young adults, and HIV and AIDS present a significant threat to the health and well- being of Canadians. You can do a number of things to lower your risk for STI. Be Knowledgeable The first step in protecting yourself is to get the facts. In this chapter we’ve provided extensive information about STIs. You can use this information to make well-informed choices that will lower your risk of infection or of transmitting an infection to a sexual partner. Refrain From Partnered Sexual Activity (Abstinence) The most effective way to avoid the sexual transmission of STIs is to refrain from engaging in sexual activity with a partner, commonly referred to as “abstinence.” For preventing infection, abstinence means not engaging in any sexual behaviours that carry a risk of transmission. This includes penile–vaginal and penile–anal intercourse, oral sex, skin-to-skin genital contact, and the exchange of body fluids such as semen, vaginal secretions, and blood. Use Latex Condoms Using latex condoms every time you have sex substantially reduces—but doesn’t eliminate—the risk of contracting or transmitting STIs. Latex condoms have been shown to be highly effective in preventing HIV transmission, and studies indicate that they can significantly reduce the risk of common STIs such as chlamydia, HPV, and HSV. Remember, to be effective as an STI-prevention tool, condoms must be used properly every time you have sex, not just sometimes. Carry condoms with you, so you’ll be prepared, and be clear in your mind about how and when you’ll bring up the topic of condom use with a partner. Limit Your Number of Sexual Partners The fewer sexual partners you have in your lifetime, the lower your chances of coming into contact with STIs and HIV. Practising monogamy (having only one sexual partner at a time) is one way to reduce your risk. Most of us will be serially monogamous, however, having a series of monogamous relationships over our lifetimes. There’s a tendency for some couples to use condoms at the beginnings of their relationships, but to stop using them as the relationships become serious. Heterosexual couples often stop using con- doms when the female partners start using oral contraception, because their biggest concern is pregnancy, not STIs. If you stop using condoms in each of a series of monogamous relationships over a number of years, you’ll have unprotected sex with as many partners as you have relationships with, which will increase your chances of STI and HIV infection. Get Tested for STIs and HIV It’s common for people to assume that if they and their partners have no STI symptoms and have been selective in their partner choices, there’s little or no chance that they have STIs. But remember, most cases of STI are asymptomatic, and STIs can happen to anybody. You can significantly reduce your risk of contracting or trans- mitting STIs by agreeing with a new partner that you’ll both be (Continued)
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414 Chapter 14 tested before having sex. If you regularly have new sexual part- ners, having equally regular STI and HIV testing is a good idea. Most doctors and clinics offer routine testing for HIV and common STIs such as chlamydia, but you may need to ask your doctor or clinic to specifically arrange tests for HPV and HSV. If you think you may have been exposed to an STI, consult a doctor as soon as possible. Early detection and treatment can make a big difference in reducing or eliminating the infection. Avoid Nonsexual Risk Behaviours Avoid contact with bodily substances from other people that can transmit infections—blood, semen, vaginal secretions, fecal matter, and so on. Don’t share hypodermic needles, razors, cuticle scissors, or other instruments that may have another person’s blood on them. Be careful when handling wet towels, bed linens, and other materials that may contain bodily substances. Get Regular Medical Checkups As part of a regular medical checkup, your doctor will examine your genitals to see if you have any visible symptoms of STI in- fection. More and more doctors are asking about their patients’ sexual behaviours, to determine whether they’re at high risk for STIs, and whether testing is needed. If you’re a woman, talk to your doctor about whether you should have a Pap test to check for abnormal changes to your cervix that may have resulted from HPV infection. A medical checkup is a great opportunity to ask any questions you may have about sexual health. Engage in Lower-Risk Sexual Behaviours Some sexual behaviours present higher risks for STIs than others. Unprotected penile–vaginal and penile–anal intercourse are high- risk behaviours. Although oral sex is less risky than intercourse for HIV and some STIs, it still carries some risk of transmission. You can lower your risks when engaging in these behaviours by using condoms for vaginal and anal intercourse and fellatio. For cunnilingus, you can cover the genital area with a piece of latex. Other risky behaviours include inserting a hand or fist into a person’s rectum or vagina (fisting). Oral–anal sex (anilingus, or “rimming”) is also risky, because of its potential for transmitting microbes between the mouth and the anus. Mutual masturbation with your partner is a good way to exchange sexual pleasure and carries lower risks than intercourse and oral sex. Some couples find that watching each other mas- turbate can be a pleasurable means of sexual intimacy, with no risk of STI transmission. Using sex toys such as vibrators and dildos—as long as you wash them with soap and water before and after you use them—is another lower-risk way to enjoy sexual activity. Rubbing your bodies together is also a lower-risk activity, as long there’s no genital-to-genital contact, and semen and vaginal sections don’t come into contact with the other person’s genital area or with breaks in the skin. Engage in outercourse , or forms of sexual expression that don’t involve the exchange of body fluids. Examples include mas- sage, hugging, caressing, mutual masturbation, and rubbing your bodies together. Make Your Own Sexual-Health Plan Many people make decisions about sexual behaviour spontane- ously. These decisions are made in the heat of passion, some- times under the influence of alcohol or drugs. One way to avoid making snap sexual decisions that may put you at risk for STIs is to make your own sexual-health plan. In other words, make some of these decisions in advance. Here are some questions you can ask yourself in making your sexual-health plan: • At this point in my life, do I want to be sexually active? • What types of sexual activities am I ready to engage in (e.g., intercourse, oral sex, genital touching)? • Under what circumstances am I willing to have sex (e.g., hooking up, friends with benefits, dating relation- ships, committed relationships)? • What steps will I take to avoid STIs and HIV (e.g., always use condoms, get tested for STIs, engage in lower-risk behaviours)? Talk to Your Partners About Sexual Health If you’re comfortable enough to have sex with a partner, you should also be comfortable enough to talk about the importance of protecting your sexual health. For example, you can mention that you’ve read about how common STIs are, and that most cases don’t have visible or obvious symptoms. This can open the way for you to bring up the topic of condom use, choosing to engage in lower-risk sexual behaviours, and getting tested for STI/HIV. Consult Your Physician if You Suspect You’ve Been Exposed If you think you may have been exposed to an STI, see a doctor as soon as possible. Many STIs are detectable in the early stages and can be successfully treated. If you’re infected with HIV, early treat- ment may keep the virus levels low and prevent you from developing AIDS. Early intervention may also prevent the dangers of an STI spreading to your vital organs. Be sensitive to any physical changes that may be symptom- atic of STIs. Talk to a health professional if you’re in doubt. outercourse Forms of sexual expression, such as massage, hugging, caressing, mutual masturbation, and rubbing bodies together, that don’t involve the exchange of body fluids. A study of adolescents in British Columbia and Seattle has found that LGB youth experience higher rates of sexual abuse and coercion than heterosexual youth (Saewyc et al., 2006). Those who have experienced sexual abuse are more likely to engage in behaviours that are high risk for STI.
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Sexually Transmitted Infections 415 INNOVATIVE CANADIAN RESEARCH THE MALE CALL CANADA SURVEY OF MEN WHO HAVE SEX WITH MEN In 2011–2012, a research team led by Ted Myers at the University of Toronto conducted Male Call Canada, a national telephone survey of men who have sex with men (MSM) to gather information on attitudes, behaviours, and other relevant factors related to HIV and risk for HIV infection (Myers et al., 2013). All the survey participants reported that they had engaged in sexual activity with a man at some point in their lives. Interviews were conducted with 1235 MSM from all provinces and territories, ranging in age from 16 to 89 years. The findings included the following: • Just over half (54.6%) of the men identified as gay, 35.6% as bisexual, 5.7% as other, and 4.1% as straight. Older men (60+) were more likely to identify as bisexual, and younger men were more likely to identify as gay. Men living in rural areas were more likely to identify as bisexual, and urban men were more likely to identify as gay. • For number of male sex partners in the last six months, 16.8% reported none, 22.3% reported one, 36.8% reported two to five, and 24.0% reported six or more. • With respect to condoms, 88.1% agreed that the ben- efits of using condoms outweigh the disadvantages, 67.8% agreed that it feels good to use a condom because it makes you feel safe, and less than half (48.6%) agreed that condoms make sex feel less plea- surable. When asked how often they used a condom for anal sex in the previous six months, 50.7% responded “not always.” • Three quarters (75%) of the men said they had been tested for HIV. Among those who had been tested, 52.2% had their most recent test within the previous year. • Less than a tenth (6.6%) of the men reported that they were HIV-positive, 67.2% said they were HIV-negative, and 26.2% indicated that they did not know their HIV status. • Of the men who were HIV-positive, most rated their mental health and physical health as good to excellent (88.9% and 87.3%, respectively). However, 82.5% of the HIV-positive men reported that they were worried that they would be discriminated against or stigmatized because of HIV. It is well known that men who have sex with men who practise unprotected anal intercourse without a condom are at high risk for HIV and other STIs. However, a common misperception is that lesbian, bisexual, and queer (LBQ) women are at lower risk for STIs. Studies in Canada and the United States have indicated that one fifth of LBQ women have a lifetime history of STI, similar to STI infection rates among hetero- sexual women, and therefore are in need of STI-prevention education (Logie, Lacombe- Duncan, Weaver, Navia, & Este, 2015). ETHNOCULTURAL FACTORS Areas of Canada where Indigenous people make up a large proportion of the population have higher than average STI rates (Public Health Agency of Canada, 2017d). For example, in 2010, chlamydia and gonorrhea rates in Nunavut and Northwest Territories were more than seven times higher than the national average. Socioeconomic disadvantage, social exclusion and isolation, and inadequate access to quality health care and services have been identified as underlying determinants of high STI rates in First Nations communities (Wynne & Currie, 2011). First Nations women are especially at risk. They’re more likely to be poor than other Canadian women, and more likely to live in environments where substance abuse and spousal violence are common (Prentice, 2005). Among Indigenous youth, STI infec- tion is associated with sexual abuse and substance abuse (Devries, Free, Morison, & Saewyc, 2009). Canada is home to recent immigrants from around the world. Their native eth- nocultural traditions and customs related to sexuality are often quite different from those of “mainstream” Canadian society. In some cases, newcomers may come from countries where open discussion of sexuality, particularly with strangers, is taboo. As a result, some immigrants may be uncomfortable seeking sexual health care (Shirpack, Maticka-Tyndale, & Chinichian, 2007). Research has found that newcomers and
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416 Chapter 14 Talking About Prevention. Most people don’t find it easy to talk frankly about preventing STIs, including HIV—but what’s the alternative? longer-term immigrants are less likely to access sexual health services compared to the Canadian-born population, and this can present an important obstacle to STI and HIV prevention, diagnosis, and treatment (Public Health Agency of Canada, 2014b, 2015). Education and Prevention A wide variety of groups in Canada provide STI- and HIV-prevention education and programming. These include the Public Health Agency of Canada, provincial minis- tries of health, universities, schools, and community groups. These programs are often integrated into broader sexual-health education programs. The most effective programs go beyond simply providing information, and try to motivate people to reduce their risks and acquire specific behavioural skills (such as negotiating condom use) to enable them to put what they learn into practice. In Chapter 15, we discuss the status of Canadian sexual-health education, includ- ing STI and HIV prevention, and the ingredients of effective sexual-risk-reduction programming. Scott Griessel/123RF
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Chapter Review LO 14.1 Identify and discuss key features and recent trends in STIs in the Canadian population. Although public attention has been riveted on AIDS for more than two decades, other STIs such as chlamydia and HPV are more common. Chlamydia, gonorrhea, and syphilis are STIs caused by bacteria. Human papillomavirus (HPV) and herpes simplex virus, type 2 (HSV-2), are two common STIs caused by viruses. The highest rates of common STIs in Canada are among adolescents and young adults, but STI rates among older people appear to be increasing. A very large proportion of cases of com- mon STIs such as chlamydia and HPV are asymptomatic (i.e., have no symptoms) LO 14.2 Describe the transmission, effects, and treatment of chlamydia. Chlamydia is the most common bacterial STI. In Canada, rates are highest among young women. Many cases have no symptoms. If untreated, chlamydia can damage a woman’s reproductive tract. LO 14.3 Describe the transmission, effects, and treatment of gonorrhea. Gonorrhea is a less-common bacterial STI that can also damage the reproductive system. Like chlamydia, it can be treated with antibiotics. However, there is concern that some strains of gonorrhea are becoming antibiotic resistant. LO 14.4 Describe the transmission, effects, and treatment of syphilis. Syphilis undergoes several stages of development. Although it can lie dormant for many years, it can eventu- ally be fatal if not treated. LO 14.5 Describe the transmission, effects, and treatment of vaginal infections. Vaginitis is usually characterized by a foul-smelling discharge, genital irritation, and burning during urination. Most cases involve bacterial vaginosis, candidiasis, or trichomoniasis. LO 14.6 Describe the transmission, effects, and treatment of HIV and AIDS. AIDS is caused by HIV, a virus that attacks the body’s immune system. As HIV disables the body’s natural defences, the person becomes vulnerable to opportunistic diseases—such as serious infections and cancers—that are normally held in check. HIV is a blood-borne virus that’s also found in semen, vaginal secretions, and breast milk. The most common avenues of HIV transmission are penile– vaginal and penile–anal intercourse without a condom and shared hypodermic needles. Antiretroviral therapy has revolutionized the treatment and prevention of HIV, allowing people with HIV to live longer, healthier lives and reducing the chances that they will transmit HIV to their sex partners. Condoms are highly effective in preventing the sexual transmission of HIV. LO 14.7 Describe the transmission, effects, and treatment of genital herpes. Herpes simplex virus, type 1 (HSV-1) causes oral herpes (cold sores) and can transmitted to the genitals of sex part- ners, resulting in genital herpes. Herpes simplex virus, type 2 (HSV-2), is usually transmitted by genital-to-genital contact and produces painful, shallow sores and blisters on the genitals. Medication can reduce the severity and frequency of genital herpes outbreaks. Herpes medication and consistent condom use can help reduce the chances of transmitting HSV. LO 14.8 Describe the transmission, effects, and treatment of viral hepatitis. Hepatitis are caused by three different viruses (hepatitis A, B, and C). Most cases of hepatitis are transmitted sexually or through contact with contaminated blood or fecal mat- ter. A vaccine provides protection against hepatitis B and D. Fortunately, new treatments that can cure most people with hepatitis C are now available. LO 14.9 Describe the transmission, effects, and treatment of human papillomavirus. Human papillomavirus (HPV) is the most common STI. HPV types 6 and 11 cause genital warts. Types 16 and 18 and other types can, if undetected, lead to several forms of cancer in women and men. The HPV vaccine can be used to prevent infections with HPV types that cause genital warts and lead to cancer. LO 14.10 Describe the transmission, effects, and treatment of ectoparasitic infestations. Pediculosis (“crabs”) is caused by pubic lice ( Pthirus pubis ). Pubic lice attach themselves to pubic hair and feed on the blood of their hosts, which often causes itching. Infesta- tions can be treated with medication. Scabies ( Sarcoptes scabiei ) is caused by a tiny mite that causes itching and can be treated with medication. LO 14.11 Identify and assess the roles of different biological, psychological, and social factors in the epidemiology of STIs in Canada. The spread of STIs and HIV is driven by a combination of factors that are biological (e.g., multiple means of
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418 Chapter 14 transmission, lack of vaccines for HIV and most STIs), psychological (e.g., perceived low risk of infection, lack of communication about risk), and social (e.g., socioeconomic status, gender inequality). Consistent condom use, limiting your number of sexual partners, and getting tested for STIs and HIV are three important steps you can take to reduce your risk of infection. Test Your Learning Multiple-Choice Questions 1. Many Canadian university students are unaware of HPV, which causes __________. (a) genital herpes (b) hepatitis B (c) genital warts (d) molluscum contagiosum 2. As many as ________ of men and ________ of women with chlamydia have no symptoms. (a) 90%; 70% (b) 75%; 50% (c) 35%; 10% (d) 25%; 70% 3. Untreated chlamydia can lead to ________ in women. (a) yeast infections (b) wasting syndrome (c) cervical cancer (d) pelvic inflammatory disease 4. Canada’s National Advisory Committee on Immuni- zation recommends HPV vaccination for __________. (a) females, but not males, aged 9 to 19 (b) females, but not males, aged 9 to 23 (c) females aged 9 to 26 and males who have sex with males in the same age group (d) females and males aged 9 to 26 5. According to the Canadian Health Measures Survey, what percentage of Canadians aged 14 to 59 have HSV-2? (a) 6.1% (b) 13.6% (c) 21.3% (d) 31.1% 6. The people living with an STI participating in Foster and Byers’ (2016) study __________. (a) were more likely to have changed sex partners in the previous three months compared to people without STIs (b) reported high levels of sexual satisfaction and sexual self-esteem (c) reported high anxiety in sexual situations (d) were more likely to have a high social sta- tus among their peers compared to people without STIs 7. Which of the following is a psychological factor in the spread of STIs? (a) multiple means of transmission (b) perceived low risk (c) the fact that many cases of STI are asymptomatic (d) socioeconomic status 8. ART is effective in treating __________. (a) HPV (b) hepatitis A (c) HIV (d) syphilis 9. Which of the following is a social factor in the spread of STIs? (a) socioeconomic status (b) lack of vaccines (c) PEP (d) the fact that many cases of STI are asymptomatic 10. Which of the following is not considered an effective prevention strategy for reducing your risk of STIs? (a) going with your partner to a clinic so you can both be tested for STIs (b) using birth-control pills (c) engaging in mutual masturbation instead of penile–vaginal or penile–anal intercourse (d) using latex condoms Answers: 1. c; 2. a; 3. d; 4. d; 5. b; 6. b; 7. b; 8. c; 9. a; 10. b
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