There are many ways to live remarkably. One way is to have more positive emotions daily; when done well, sex creates many positive emotions. Because sexually-active singles have more sexual partners than partnered people, sexually transmitted infections (STIs) are of greater concern for singles. Fear, misinformation, and stigma keep some singles from experiencing the joys of sex. Peter McGraw invites Jill Cohen and Greg Burns into the Solo Studio to discuss the risks and rewards of sex and best practices for testing, treatment, and disclosure of STIs.
Listen to Episode #134 here
Rewards And Risks Of Sex: STIs
I talk a lot about the many paths to living a remarkable life. One of which is to have more positive emotions on a day-to-day basis. When done well, sex creates a lot of positive motion. Much is made of data that shows that married people have more sex than single people but less is made about the quality and variety of that sex. Indeed, sexually active singles have more sexual partners than partnered people. As a result, STIs tend to be more of a concern to singles. Fear, misinformation and stigma keep some people from experiencing the joys of sex.
I invite Jill Cohen and Greg Burns into the studio to discuss sex and STIs. Jill grew up in Miami, attended Emory University and received a Master’s in English from the University of Colorado. She resides in Boulder. As a traveling ER and telenurse, she’s worked in Colorado, Wyoming, California, Florida and Australia. You may recognize her voice as a previous guest on episodes, What Makes a Life Remarkable and How To Go on a Date?
Greg is the CEO and Founder of Defining Spaces, a one-stop shop for real estate agents’ listing needs. A Hoosier by birth and a Sandlapper by relocation, he received his undergraduate degree from Winthrop University in South Carolina and did his postgraduate work in New York City. He lives in Denver with his pug, Cornelius Pugsley.
To help you make better-informed decisions, we discussed the risks of STIs and the rewards of sex, as well as best practices for testing treatment and disclosure. The usual caveat applies. This is not meant to be medical advice. Please consult with your medical professional for your specific needs. I have a brief correction. At one point, I talk about taking home STI tests. Those tests involve both a blood draw and a urine sample. I omitted the blood draw from the discussion. I hope you enjoyed the episode. Let’s get started.
You’ve been training your whole life to be here at this moment in time. Is that right, Jill?
Yes, in some ways. I went to nursing school in 1996 because I had this moment. I was teaching English at CU. I heard a woman named Sarah Lochner on the radio talking about STIs and doing health education, disease prevention, birth control and all kinds of reproductive health stuff. When I heard her giving her radio show, my thought was, “That’s what I want to teach and do with my life.” I tried to figure out who was doing that work. It turns out nurses were doing that work, one of the groups of people who were doing that thing. I went to nursing school.
It’s a very roundabout way that I got here. I started as a cardiac nurse. I went to the ER and then I’m doing primary care. A big part of my work in primary care is testing education and management of sexually transmitted infections. Somehow, Peter and I got to talking about that. He asked me to be on the show and my whole life came full circle at that moment. I don’t know. Here we are. I’m on the radio talking about STIs like my hero back in 1996.
Welcome back, Jill. This is your Sarah Lochner moment. Welcome, Greg. You’re new to the show. You came highly recommended by a regular voice, Julie Nirvelli. She was going to be in your exact spot. She said, “Greg would do a much better job.” No pressure either. We’re here to talk about STIs, Sexually Transmitted Infections. This topic has been requested multiple times from multiple members of the Solo community, which you can sign up for at PeterMcGraw.org/Solo.
A couple of quick notes, we are likely to talk about safe sex but probably not with regard to birth control and more with regard to minimizing risk. We’re going to talk about consent and disclosure but we may not cover the full range of those issues. That’s important and probably, they’re going to get their episode as a result.
As Jill has already mentioned, she’s here because she has this medical training, I’d say boots on the ground. She is dealing with this every week. She’s working with people who are being tested and treated. Greg is here as the man on the street or rather the man in the sheets to give his perspective. This topic did come up at a game night one night. I can’t remember why STIs came up and Jill said something to me. I immediately said, “We have to do this episode.” She said, “There’s no shortage of facts. That’s not the problem.” What is the problem?
The problem is the reluctance and reticence to have conversations about sexually transmitted infections. As it turns out, the more conversations that are open and honest that we have about STIs, the studies show that transmission of STIs is reduced in those instances. We are doing our part by talking about it.
Do you agree with that assessment?
I agree with her.
There are issues of safety and risks that we want to talk about. This is my perspective. The conversations are often much more nuanced than the data that we get from one-way broadcasting, whether it be your health teacher in junior high, PSAs or whatever it may be. With this notion of risk versus reward, sex intimacy is incredibly pleasurable. Positive emotions make our lives better.
These experiences can bond us to other people in important ways and yet some people enter them scared who don’t enter into them. This can be a fraught feeling that people have. One of my goals for our conversation is to talk about this balance and the trade-offs. Why don’t we start with this? Before we get into the blocking and tackling of various STI testing, do you have an overarching perspective about this experience opinion?
One of my overarching thoughts about this is that it is nuanced. I want to frame it in terms of the so-what factor. For anything that you write and talk about, it’s like, “Why are we writing or talking about this? So what?” The overall so-what factor for this for me is that STIs, while they are manageable, curable in some cases and associated with this wonderful pleasurable connecting activity that human beings share, they’re a risk of that connection and not desirable even though they’re manageable and/or curable.
There are plenty of other things that are transmitted infections that are manageable and curable but people don’t even blink if they’re dealing with them.
It’s because they carry no shame. Another important so-what factor is we carry much shame about this.
When I was in college, I had an athlete’s foot. I’m not proud of it but I wasn’t shamed as much as I should have been for having it.
To piggyback that, we’ll talk about getting a cold, flu, COVID or anything like that but it’s like, “I’ve got herpes. I have this out or the other.” It’s not a common place to be spoken of. As gay men, we speak of those things a lot in our community. I don’t know if that goes back to HIV and we had to protect ourselves. There’s a lot of stuff that went on with that in the ‘90s. I came out in the ‘80s and lived through the HIV pandemic. It was very different. We got used to communicating about that. It’s not shameful for us to ask.
I’ve had a couple of dates. One of the first conversations we had was, “When was the last time you were tested? Do you get regularly tested? Do you have anything?” It’s a commonplace conversation. I have many heterosexual friends, especially females. Probably about 4 out of 10 of them have herpes. They’ve been honest with me about that but they don’t tell anybody else. They’re shamed about it. They’d say something to their partners before they sleep with anybody or have relations. I encourage them to open this up and take away the shame, at least around me. That doesn’t have to happen.
The gay community that I’m associated with is very open. Everybody talks about it. Even on our apps, there’s a button you can hit. This is where you go get tested if you need to get tested. Here is the information. A lot of it is data. “Where should I get tested? Should I not get tested?” It makes it easy for people to give them the information.
We’re going to foreshadow this and talk about some of the places where you can get tested. There are a lot more options out there than people often realize.
What’s great about that is two things. One, the more you do something, the more natural it feels. That’s something I want people to hear because if you have a diagnosis, you might feel uncomfortable talking about it, particularly if it’s a new diagnosis. Every woman aged 20 to 50-ish, should have a bossy gay friend who they can have these conversations with and practice. The other thing is when you get there, the realization that happens is that the way I feel about this is congruent with what it is. Herpes is a skin condition. I’m going to geek out for a second here on the history.
This is going to be the first of many moments where Jill drops this little nugget and you’re like, “I didn’t know that.”
Nugget number one, we came out with penicillin to treat gonorrhea and chlamydia in the ‘50s-ish, give or take. Prior to that, herpes did not have a stigma. People treated it for what it was. You get some blisters and they go away. You get a pimple and they go away. Eighty percent of the population has HSV-1 in their mouth. It’s estimated that about 1 in 5 people in the United States has genital herpes. That’s been pretty consistent. It’s common. People regarded it as such.
However, when we came up with antibiotics, gonorrhea and chlamydia, all of a sudden, we were like, “You can cure those in a second.” Those were no longer stigmatized. People who wanted to use sex as a moral weapon for behavior control in religious organizations needed a new scapegoat. The one thing about it is that it’s not curable. It’s very manageable. Herpes became the STI that was weaponized to control people and it became highly stigmatized.
I’m glad you brought that up because part of the reason there are lots of information but not conversation and certainly, a little nuance is there are interests out there that don’t want you having sex. Some of it is they don’t want you having sex before marriage or they don’t want you having sex unless you’re going to produce a baby.
It’s going to cause Armageddon, the rapture, the end of the world and the end of days if there’s all the sinning going on.
There’s all this stuff happening. There are these vested interests and fear is a great way to control people. Herpes is an excellent case study. We’ll go even deeper into it in a little bit here but it’s not like when I was a teenager or twenty-something, I had a lot of opportunities to have sex. I certainly was living in a generation that was terrified of sex. Between HIV and herpes in the ‘80s and ‘90s, it was very scary out there.
I’m not blaming that for my lack of sex but it contributed some. In the ‘80s, Time had a headline, Herpes: The New Sexual Leprosy. In ‘85, the FDA approved an oral suppressant for herpes outbreaks. Suddenly, there were all these magazine ads and help-seeking ads that became popular like, “If you’re having this problem, ask your doctor about this suppressant.” It became lucrative to make this scary to have people doing this.
People who had it would be motivated to treat it. Arguably, there are better ways to motivate people to treat the conditions they have and reduce transmission. It doesn’t mean that you’re a bad person if you have this but that’s what the marketing was geared towards. Certainly, they were putting a negative stigma on having this skin condition.
I’m a scientist and I was curious about the stigma, the concerns, the worries and so on. Do they match up with the risks? I ran a study. I asked 125 unmarried people to rank a diagnosis from worst to least worst of a variety of different STIs and how they perceive it. First of all, it did not go exactly as I expected and in a way that feels good in a sense. What I’m going to do is take us through the results. For each of the STIs, we can have a conversation if that sounds good. Maybe we can do some myth-busting and get into some detail here. You can guess probably what was number one worst on the list.
It was the lowest variance response. Almost everyone in the survey put it as number one. It wasn’t unanimous but it was close.
Are these random people? Did you know them?
It’s not the most rigorous study. It was done through an online panel. These are people in their 20s, 30s, 40s and 50s and unmarried. The survey said sexually active people. There could have been some non-sexually active people who responded. It is overwhelmingly heterosexual and the breakdowns are close to male and female. It might be slightly more male. I didn’t do a deep dive as I mostly have the rankings. Let’s talk about HIV. HIV hasn’t changed but the world has changed.
It used to be a death sentence. It’s not anymore if it’s managed well.
Why is that?
There are many ways to manage and treat it. Lots of testing is encouraged so that it’s caught early. There’s lots of education about it. People know to get tested and what the symptoms might be. When it’s diagnosed as HIV, there’s ART, which is Antiretroviral Therapy. It equates to a pill a day, regular lab testing and risk management. Most people who have it live a long and healthy life, including healthy sex life. With antiretroviral therapy, you can get your viral load down to undetectable. When you’re undetectable, you can’t transmit.
If you go to gay apps or something, they’ll have, “Are you HIV positive and undetectable?” People do positive with a negative next to it. Positive but undetectable means they’re on this medication.
One of these is PrEP, Pre-Exposure Prophylaxis.
PrEP is a way to manage the transmission. This is a pill a day managed by a healthcare provider with regular testing. You can go on PrEP to prevent yourself from contracting HIV from someone. Let’s say your husband is HIV positive. You can have sex without a condom if you take PrEP every day at the same time without getting HIV yourself. It’s highly effective at preventing the transmission of HIV.
One of the members of the community, I announced that we were going to do this episode and she wrote, “In reference to questions in topics for safe sex STIs, it will be important to discuss PrEP for the prevention of HIV being available to all regardless of gender or sexual orientation.”
It is available to all. I have some patients who work in the adult film industry. That’s usually where I see women taking PrEP. There are two medications for PrEP. Generally speaking, they’re coming out with injections that you can go for a longer time and come in for an injection monthly. It brings me to another point, which is that this is always evolving and changing. It’s good to stay up on it and look at your resources. We can list them now or in the end but there are ASHA, the American Sexual Health Association, Planned Parenthood, The STI Project and the CDC. There are a lot of resources out there. Those are my favorite ones that I listed.
ASHA is where we do most of the stuff because we have clinics, at least what I’m used to. It’s almost pop-up clinics. A lot of them are through Denver Health here in Denver, in the Metro area. We go and take your blood. They do everything. You can almost do an instant test for HIV to see if you’re positive before you go on PrEP. Blood work that has to happen quarterly, if you’re on it.
If I understand this correctly, you can be HIV positive and do this or negative and do it. Is it different between the two situations?
It’s different medications.
One controls when you have it and the other one keeps you from getting it.
There can be side effects and that’s why we do the quarterly testing. The main one is kidney failure. It’s rare. I have hardly ever seen a patient who has problems with their kidneys when they take PrEP. If they do, we switch. Usually, people go to Truvada. It is the first line. You can go to Descovy if you wind up with kidney problems. That’s another medication. Generally speaking, people have fewer side effects with that one but it might be more expensive. You have to get prior authorization from your insurance to be able to take Descovy. You have to fail Truvada if you want to go on Descovy.
One thing I’ll add to that to echo some of it is a lot of people don’t have health insurance. That’s a big issue. PrEP can be very expensive if you don’t have it. However, you can if you go to Denver Health. They’ve got a wonderful office there. They will go through and find ways to get it to you relatively cheaply, if not for free.
I’m speaking from a man in the gay community. I’m not sure about other things. I’m sure the resources are available to everybody, not just a person who’s gay. It can be pricey but it takes more research to go find those places. You have to ask people questions and do things. That’s got a stigma itself. You’re like, “I’ll deal with that tomorrow,” when it should be dealt with now.
I talked about this with a lot of my female friends and straight male friends’ counterparts. I was like, “Should you not look at getting on PrEP?” They’re Like, “We don’t get that.” I was like, “Don’t you?” It’s a little bit of ignorance around it that it’s a gay thing still but we’ve circled wagons around our community. We know where to get it and who to talk to. We don’t have a stigma about bringing it up. It’s almost the opposite. If you’re not taking something or taking care of your physical health, you’re a pariah. You’re shunned in the community a little bit if you’re not getting tested quarterly for everything.
You’re not following best practices. For the heterosexual community, there aren’t best practices that are being discussed.
We’re a little behind in the heterosexual community as far as the comfort with talking about things, being open about things, getting tested, treated and prevention. Not that we want to have something like HIV run through any community to spur people to be proactive and protective of themselves and other people.
I moved to New York City in the early ‘90s. It’s the height of HIV and everything. It still was a death sentence then. We have these COVID cards. We have to walk around and show if you’ve been vaccinated. We are going with our tests and we will show them to our dates or people. We had to for self-preservation.
We got tons of education. We would leave flyers with people. We went to the gay and lesbian centers. We did whatever we could do to educate ourselves. We had to talk about it because if you didn’t, the alternative was probably death. Ignorance was not an option at that point. I lost a lot of acquaintances than real good friends because I was coming in new to New York at that point. I remember rocking, aids, babies and things of that nature. People were like, “Have you heard the latest where this medicine is being tested?”
We were shunned and put back in the closet a little bit because of that. Accordingly, there weren’t resources in the vast community until it went to the straights community. That’s when everybody started, “We got to take care of this.” We’re going into the hospitals that we were in, the facilities that we went to and the doctors that would treat us to get all their information to take back to the upper side hospitals.
It was interesting to watch that in the ‘90s, growing up with that around that we did put this bubble around us to make sure that we were protected and also in the emotional bubble to help each other. “Do you need food? Do you need this? What’s going on?” Some people were okay with it. Some people are drastic and fast. People ask me, “Why are we so open to talking about it?” Being gay men, we had to and it’s an inherent thing. I hope we don’t lose that with subsequent generations. I’m still seeing young people talk about it all the time on PrEP right away, as soon as they can, because they do want to be sexually active and be safe about it. They set the majority of what I come across.
To get back to your friend’s question, I want to reiterate that PrEP is available to women. It’s always to go on medication. It’s a conversation to have with your healthcare provider. If you’re a woman and you think you’re at high risk of contracting HIV, you should go make an appointment or go to a public health clinic like Denver Health or whatever city you’re reading from. Planned Parenthood is great about this thing. It is available to women.
To echo your point about insurance, Greg. PrEP is supposed to be under the Affordable Care Act, free to anyone who wants to take it. It says the wording is funky on the CDC’s page. It says, “It should be covered under most insurance plans.” What it takes is comfort, going, jumping through the hoops, dotting the eyes and crossing the heats to get it. There are resources there. It is supposed to be free for someone who wants it.
The oasis is these major urban centers, the places that you might need to seek out. If you live in the suburbs or rural places, you might need to make a trip to the big city for the best resources.
I mentor a gentleman who’s in the Southeast of Colorado and he wants PrEP. He gets his through the mail. I’m not sure how he does that but there are a lot of resources that way. If there’s a will, there’s a way to find information and you can go get it. Every clinic I’ve ever been to, no one’s ever come at me, looking at me crossed like, “You need PrEP.” There’s no shame involved. People need to know that their healthcare providers don’t shame them when they go in and look for something. No matter what it is, people need to talk and be open about it. They can’t help if you don’t tell them, ask them questions and educate yourself. Ignorance is no defense against these things.
I’m smiling because what I think the average person fails to realize is the stuff that these medical providers see regularly. They’re like, “You’re boring.” I had an STI scare. I was calling and texting Jill. She was nonplus. She was like, “This is what’s asking me questions and everything.” I had nothing to worry about with regard to her. I had a partner who got chlamydia and told me a thing. I was like, “I got to get tested, do these things and all this stuff.”
Good for her for telling you. That’s awesome.
You were running off to Europe. The timing was difficult.
If I have to deal with this, I don’t want to have to deal with it overseas. Europe might be even better suited in some ways. As a reminder to someone who’s walking into a clinic, whether it be Planned Parenthood or a public clinic, know that whatever questions you have or behaviors are, they’re well within the norms of what these people are encountering.
By that same token, as a healthcare provider myself, the way I try to do it and I hope this is how other people are received as well, is that I understand that it’s a big deal for the patient who’s coming to me because it’s not the 87th time that day they’ve dealt with STI. It’s my normal, not theirs. The way I try to do it and I hope a lot of healthcare providers try to do this is I get it. This is a big deal for you but I want you to know that I can help you with this. This is something I deal with regularly. I’m comfortable and confident dealing with it. I can help. Let’s get through it.
I’m not going to go in order. I’m going to go from the lowest variants, being the distribution, to the highest variants. This STI, in some cases, was high and in other cases was low on people’s risks. Some people ranked it bad and some people ranked it as not bad at all. Do you guess as to what STI that is? I can give you a hint if needed.
It was pretty evenly distributed. Half of it was horrible and half thought it was not too bad.
It had a lot of variants. It showed up in various places. The thing that predicted it was gender.
What does HPV stand for?
What is it and why was it perceived by some to be risky and some less risky?
It occupies both of those polls. HPV is super common. To the tune of, we don’t even test for it if you’re age 29 or under because we assume you have it. Most people with a healthy immune system get HPV. They have it and it’s asymptomatic. They can transmit it but it’s most likely they don’t even know they have it. The body clears it up in its own time. I could compare it to having a cold in these instances where you get an infection, your body fights it and it goes away. It is transmitted by sexual contact. Both men and women can have it.
Are there symptoms?
It can cause genital warts. It doesn’t always but it can. The body clears it on its own. We don’t even test men for it because it rarely causes any problems. If you are a man and at high risk of getting HPV and it can happen, the way it can be problematic and troublesome with men is if they get it anally, we test and do anal pap smears with some men. It’s something to talk to your practitioner about if you think you fall into that category.
With women, we’ll test you for HPV with a pap smear after age 29. If we detect it, we’ll check you again in a year. The algorithm for when we test is complicated but here’s why people might have ranked it as a big deal. This is why I’m saying, “It’s no big deal.” We all get it and get rid of it, generally speaking.
However, if left unchecked, it is the only STI that can give you cancer. Keep in mind. It takes 10 to 20 years for it to develop. It’s slow-growing cancer. It doesn’t often happen because we’re good at testing for it after age 30. If we detect it, we keep an eye on it at closer intervals. We get it before it turns into cancer. With that being said, some people were probably like, “HPV is the bad one.”
It is because HPV equals cancer in their mind.
Cervical cancer, ovarian cancer and reproductive cancers in women, if left unchecked, can be fatal.
I want to be clear. The way to this should be part of your regular healthcare. A woman should be getting a pap smear regularly.
You start when you’re 21. If it’s normal, you go to a 3-year interval and then a 5-year interval. Your practitioner is going to look at your particular situation and decide on the right screening interval with you. It can depend on a few different things but generally, we’ll recommend either if we find some troublesome changes to your cells or HPV and it adds up to, “We need to go look at this more closely,” then you might have another procedure called colposcopy and we do some treatment from there. If it’s normal, the screening intervals are farther apart. If you get several normals in a row, you go to five-year intervals. I’m saying all these generally because there can be individual variations. It’s important to talk to your provider about stuff.
This is not officially medical advice for you. If a woman is sexually active, has multiple partners and is non-monogamous, she is likely to get a pap smear more often.
No, it’s if you test positive for HPV, 30 or after. It’s also combined with how your cells look. What HPV does is it’s a virus that can cause changes to your cervical cells that can become cancerous and that’s how it causes cancer. It’s a combination of looking at, is there HPV present? Are there some cellular changes? To what level and degree have the cells changed? We decide on the screening interval and interventions.
It sounds to me that like HIV, there’s a lot of prevention. You’re wearing condoms and doing testing. You might be on PrEP. You’re having these conversations. You’re doing all of this stuff to try to avoid transmission. HPV, in general, you look to detect.
That’s true because most of the time, it has no symptoms. There are varying stages of the STI. HIV can be transmitted asymptomatically.
I wonder if some of the variants with the responders were the commercials that are out there like, “HPV, get the vaccine and stuff.” My niece, when she was young, my sister went through all that, “Should I give this to her? Should I not?” There’s so much noise, at least for someone that sees it that way.
I’m glad you brought up the vaccine.
It’s on television consistently. I don’t watch much TV but I would think every time I turn it on, I see a commercial for that.
What’s the story with that?
It’s great because the vaccine can prevent nine types of variants of HPV that we found to be the most dangerous and the ones that most often lead to cervical cancer. They made a vaccine that targets those and helps prevent those.
Are these teen girls take it typically?
At age nine, you can start getting it around there.
My niece probably got it at 12 or 13 years old.
It’s young. It’s middle school. Initially, there was a lot of fear among parents, “If my daughter gets this vaccine, she’s going to start having sex.” I don’t think the vaccine is what’s going to be the deciding factor there.
Do you know what is going to get your daughter having a lot of sex? It is telling her not to have sex.
That’s the best way to push her right into bed.
Arming her with information is a terrible thing to do.
If you get it when you’re young, it’s a two-vaccine series. If you decide to get it later in life, age 25 to 45-ish, give or take, it’s a 3-shot series. It’s a great vaccine that helps protect you from getting this virus, which most often doesn’t cause cancer but when it does, it causes cancer.
That was HPV. It wasn’t next on the list but it was so interesting that it had such high variants. The next most challenging, according to the respondents, after HIV, I was surprised by this one, was syphilis. Do you consider that to be an accurate response?
I think so.
What is syphilis?
Syphilis is a bacterial infection and it’s transmitted sexually.
We’ve been talking about viruses to this point and then you said, “Bacteria.”
Syphilis, gonorrhea and chlamydia are bacteria. HIV, HSV and HPV are viruses. Syphilis starts mild enough. A lot of people don’t even notice the first sign of the infection. It’s the size of a pea. It’s like a sore and ulcer. It’s painless on the genital. It often goes unnoticed. It shows up about an average of three weeks after you get exposed and it goes away. There are four stages. That’s the primary stage. The secondary stage is a lot of people get a full body rash. That gets their attention.
To back up for a second. He’s not noticing that they have a pea size lesion on their genitals. Do people not pay attention to their bodies?
If it’s in a place that’s not very visible, the problem is it’s painless. It can be on the inside of the vagina. It can be on the backside of the penis. If it doesn’t cause you any pain, that’s why people aren’t noticing it.
I’m going to venture the guesses. A lot of times, people are not as in tune with their bodies as you might think that they are in terms of comfort and paying attention. There might be that denial. It’s like, “It’s scary.”
If I ignore this, maybe it’ll go away, which it does but it always comes back once you get it back. The rash is secondary. The latent stage, that’s the third stage. The tertiary stage is bad news. It hardly ever gets there though because most people do get treated when they get the full body rash. It’s a big signal to about every healthcare provider when someone gets a rash, “It might be because you were in the hot tub or you tried a new detergent.” It could be syphilis. Every healthcare provider worth their salt should be thinking of syphilis when a sexually active person presents with a full-body rash.
How long is the latent period?
It’s 2 to 10 years. There’s some huge variability with syphilis but here’s the problem. This is why people ranked it higher. It’s making a resurgence in how common it is. It’s made a comeback. That’s why it’s got people’s attention and it’s very treatable.
Some famous people had syphilis and it causes major mental problems.
Neurosyphilis is serious. It can affect your hearing and anything where your nervous system is involved. It can cause dementia, neuromuscular problems and hearing problems. It can be very damaging if left untreated but I don’t want to be doom and gloom. It’s manageable. It’s shots of penicillin and that clears it up. I’m sure we’re going to get into a section where we’re talking about how often I should get tested. If you’re sexually active, you should be getting tested and a test will pick it up, even if you’re asymptomatic.
That’s what I was going to ask. Let’s suppose you had this sorry to notice it and it was painless and you’re getting tested every three months. It’ll pop up.
It can take a little bit to pop up. Let’s say you get infected. You get tested a week later. Probably, it won’t pick it up at that point but when you get tested three months later, it will.
If I could pause like a quick PSA, if you’re sexually active, you’re going to want to create a system in which you’re being tested regularly.
Once you find your place or places that you go, you’re in and out. They’ve got it down to a science. I’ve never spent more than a handful of it. Some of the tests, they could do onsite. You’re better to speak about that, Jill, but they can go through. Something that calls you later or your MyChart, they log and put all your information and then you can download it when it’s available. It’s quite simple. It’s as quick as going through a drive-thru sometimes. I want people to know that this is not a difficult process. This isn’t like, “I’ve got to go to the dentist and be there for hours.” It’s nothing. It’s simple.
We’re going to get into it more deeply but I wanted to pause there in case someone stops reading once we get to the one they care about within your community, syphilis.
We checked for all of that. I had a partner a few years ago that called me and said, “I’ve been exposed” I went and got tested. It wasn’t right away. That three months to what Jill’s point was, I went back and I said, “This happened 4 or 5 months ago. Could you double-check? It never popped up.” I want to congratulate that person for letting me know. The communication is there quite a bit.
You can notify partners anonymously if you’re not quite there yet feeling comfortable. There’s TellYourpartner.org and STDCheck.com. All you have to do is google anonymous partner notification and there are ways to do it. If you’re notified, you can do testing and treatment on the same day. We call it a known partner exposure.
This is like a prophylactic treatment.
If my partner tells me, “Jill, I tested positive for chlamydia. I wanted to let you know because we slept together.” I would say, ‘Great, thank you.” I would call my provider and say, “I was notified by a partner that they had chlamydia.” This is why we’re educating people. Most healthcare providers are good with this thing but there might be a few that are behind the curve. You can go and pee a cup and get tested but also get your doxycycline that day because chances are you might get it so why mess around?
Let’s talk about doxycycline for a moment because since we’re talking about syphilis, it’s going to come up again when we get to chlamydia.
It’s penicillin for syphilis and doxy for chlamydia.
Thank you for clarifying. Some of these prophylactic response is like, “Let’s take care of it, soothe your concerns and head off the fact that you can resume normal activities sooner rather than later.” Is there a downside to this?”
With the non-judicious use of antibiotics, we’ve developed a lot of antibiotic resistance and that’s certainly a downside. Someone might be allergic to an antibiotic and discover it because it got prescribed to them. You can have gastrointestinal upset.
There are some side effects like sun sensitivity.
For the community, antibiotic resistance is an issue. However, I don’t think this is a non-judicious use of antibiotics because you had exposure. An infection is likely to develop. You can wait to get treated and opt for that but it’s something to discuss with your healthcare provider to let them know and to figure out what you think would be the best course.
It usually takes about fourteen days for an STI to show up on a test. You can say, “I’m going to mark my calendar fourteen days after this exposure. I’m going to get tested. If I’m negative, unless I develop any symptoms, I’m going to call it good and not get treated. That’s how I feel comfortable.” That’s an okay way to go but you have to wait that fourteen days because if you test it for seven days, you can’t trust a negative result.
That’s one way to go about it and that’s okay. Other people are like, “I don’t want to risk the effects I might have from getting the STI.” Usually, early in an STI, you don’t get horrific symptoms but it can cause burning with urination and foul discharge. Some people are like, “I don’t even want to deal with that.” Untreated for a longer period, women can get a pelvic inflammatory disease. That is something that can happen. With men, they can get epididymitis and uncomfortable symptoms that you can stop before they start if you treat them prophylactically after an exposure.
It sounds to me this is a risk-reward situation. The next one won’t surprise you because we’ve already alluded to it and the fear around it. That is genital herpes. It sounds high on the list, higher than it probably deserves to be given what Jill mentioned at the onset of this conversation.
I almost thought it would’ve been second after HIV.
I did too. That’s why I was surprised about syphilis. There are so much fear and stigma around it for the reasons that we’ve discussed. I was happy that it was lower. It doesn’t sound like it’s as low as it should be.
Syphilis is above it appropriately. Gonorrhea and chlamydia can ultimately cause worse problems for you. They can cause infertility. Herpes can’t do that.
What else should people know about herpes that we haven’t talked about?
I have real-world experiences when I talk to people and this is for my observation with my group of friends. I’m very open and I want to talk about these things. The shame needs to go away. If you’re sexually active and you want to do things, I want people to have the knowledge to go be sexually active and enjoy themselves but arm themselves with information and/or protection, whatever they need to do.
I find almost always women will come to me. I’ve got two female friends who contracted genital herpes from a partner they didn’t know. They’d been with for years, casual partners that they’ve known for a long time. The gentleman didn’t know. There was an outbreak and it threw them in a tailspin emotionally. They had to go back to their therapist and their doctors were similar to what Jill was saying. It was like, “It’s not a big deal. We can give you a pill a day if you want or you could wait and see to find the best course of action for you.” They’re both shameful about it. I tried to find as much information as I could.
I have one friend from New York and she is mad about it. She tells everybody in the world, “Yes, I have it. This is the information you need. Don’t shame yourself. Don’t shame women. We’ve already been shamed enough and put down enough about being sexually active, to begin with.” This is like, “I told you not to do it. Look what you got.” They have to deal with a lot of the emotional baggage that comes with being a sexually active female.
If I sleep with five people a week, I’m a stud. If a woman does it, she’s not. It’s different words that are used by different people. I hate that and it bothers me. I always encourage women to talk about it and make it less stigma-ish, at least for their generations. These two ladies I’m speaking of directly are under 30. It’s interesting how they still have that shame. They didn’t grow up religious or anything of that nature. I’m like, “Where is this coming from?” That’s what I don’t like about the herpes thing because it seems like that’s the worst diagnosis than anything. If you tell somebody, you file bankruptcy before you would do that. Let’s talk about that. I don’t understand that.
You make many great points here. One is that your STI diagnosis, whatever it is, is not going to be the worst thing that anyone brings to a connection or a relationship at all. There are way worse things. The other thing that you touched on is that your STI status is not a badge of honor if you’ve never had an STI and it’s not a scarlet letter if you have an STI. It doesn’t mean you’re virtuous if you’ve never had an STI. It means you’re lucky and maybe you haven’t had it yet or you don’t know you have it.
I have 1 observation about herpes and 1 about STI, in general. For many years, I went to Planned Parenthood to get tested. They often ask you, “What do you want to get tested for?” What you want to say is, “Everything.” What the clinician will often say to you is, “Unless you have an outbreak or a specific concern, we don’t test for herpes because the stigma of knowing you have it is worse than having it.” These are my words. Is that a fair way to say it?
There might be some truth to that but I want to get to the other reason that the blood test for herpes is with problems as a screening.
Can we pause that so I can say my other thing? It’s around STI disclosure more generally. I’ve seen this on apps, especially more sex-positive apps and it’s like, “Don’t use the word clean.”
I was waiting to find out when I could say that. There are few things in this world despise and that is one of them. If someone will ask me on an app and they’re reaching out to me like, “Are you clean,” I block them right away. It infuriates me because you’re telling me that I’m dirty.
If you have an STI, you’re dirty. If you don’t, you’re clean. It feels too moral.
There are also things people will ask me, maybe not as much now but back in the day like, “Will you date me if I’m HIV positive?” I’m like, “I will be intimate with you and do all those things.” My point is you don’t catch STIs from people who tell you they have them. You know how to protect yourself and go about things. Especially when it was HIV back in the day, you have partners that had it and partners who didn’t. You come together and find a way to do that. When people would say, “Clean,” I won’t go on a rant too much but it bugs me so much.
You’re shaming somebody for being sexually active or for doing something pleasurable to them that they are doing. You’re on the app as well asking. You want me to disclose things before you will. You don’t want to be vulnerable but you want me to do it. That’s another thing that bugs me but I’ll get off the soapbox on that.
What should people say?
“What’s your status? Have you been STD? Have you been screened? Have you gotten regular checkups?” If you’re old enough and I want people to have as much sex as they want but responsibly, these conversations shouldn’t be difficult at all. Do you want them to wear a condom? Do you not want them to wear a condom? Those questions should roll off your tongue and the more you do it, you go get tested more. If you have these conversations, the easier it becomes. Starting with young people and giving them this knowledge but asking someone if they’re clean. “What does that even mean? Yes, I shower now.”
There’s a flip side to it because some people will advertise that they’re clean.
Everything is opposite when it comes to that for me. If you say that, I might know you’re not.
It’s a bit of a yellow flag because many STIs are asymptomatic. It could be that this person doesn’t know they have an STI.
You’d be better off saying something like, “I’m regularly tested.”
I’ve been tested and the last time I got tested, these were my results. It was back in May 2022. I’ve had a couple of partners since. Let me know if you want me to get tested again or if using condoms is okay. What do you feel comfortable with? That thing would be nice because getting back to the testing thing, we test depending on what the risk profile is, what people tell us about their exposures, what types of partners they have and how often they use condoms and do not use condoms. That’s how we decide what to test for and how frequently.
Pretty much we’ll test you whenever you want to get tested. We’ll also educate and say, “When was the last time you had a risky exposure?” “It was three days ago.” “We can test you. We also recommend testing you again fourteen days after that exposure because you might not pick something up from that exposure this time.”
Getting back to the herpes question. I want to mention that one of the reasons why people feel heavy about a herpes diagnosis is it’s not curable. It does last forever. This is something that you’ve got for the rest of your life. You’re going to be disclosing it many times. It’ll feel better the more you do it. However, it’s another thing that you have to deal with in your life. It’s manageable but not desirable. You prefer not to.
When you have a herpes outbreak, they’re painful. People do not enjoy them because they can be quite uncomfortable. As far as testing, when you have a suspicious lesion, that’s a time to not only get tested. That’s a time to go see a practitioner. If you have any symptoms like discharge, ulcers, blisters, spots or anything that is not normal for you and it’s visible and palpable, it’s not only testing. It’s an appointment. I want to make sure we say that.
That provider said that was accurate unless you have something I can swab. Screening with a blood test for herpes, at that point, you’ve switched from testing for the actual virus to testing for antibodies to the virus. Antibody testing can be fraught with problems. One is it takes our immune system a little while to build up antibodies. With HSV-2, there are two types of HSV.
An HSV-2 is genital herpes, generally.
The most common new HSV infection in the past several years is HSV-1 in the genitals because of all the oral sex we’re having. Good job, people. We were having lots of oral sex. Side note that I’ll say, HSV-1, when it occurs in the genitals, it’s not as severe usually as HSV-2 in the genitals because it’s home base. It doesn’t thrive there but it can be active there and you can get it there. When you’re doing the blood test for antibodies, after three months from exposure, that’s when 80% of people will test positive for HSV-2. You can see why this is an issue. You get a negative test. You’re like, “I’m good.” It could be that you tested too soon.
If you get a positive test, there are a lot of false positives. This is what she’s talking about. It can cause a lot of consternation, fear and anxiety that you have when sometimes it’s a false positive. The test is registering an antibody that’s similar maybe but you don’t have HSV. That’s an issue. When you get something called a low index value on a positive test, in those instances, it’s very much falsely positive. You have to go for further testing to confirm.
You’re trying to figure this thing out that may never be an issue for you and it’s common.
When someone comes in and says, “I don’t have anything going on. I want to get my screening,” screening is when there’s not a good reason like getting my regular test. That’s when we say, “The negatives outweigh the positives with the HSV blood test.” There are some instances where we think it’s not a bad idea to get an HSV blood test. One is if you’ve ever been told you have HSV on a visual diagnosis only because experts in this are wrong 20% of the time on a visual diagnosis only. A lot of these things look similar.
That’s one instance where you’ve been told by a provider you have HSV. They never did a test. You might want to get a blood test. That’s one. Two, if you’ve had unusual symptoms, you’re not having symptoms now but you had some that came and went and you’re not sure what they were, maybe that’s not a bad idea to get the blood test.
If you have a partner who has HSV and you regularly have sex with them, you want to see if it’s been transmitted or if you have a lot of sex, you’re at high risk, you’re constantly exposed and you want to do it for that reason because your risk is high, those are all things to talk about with your provider and see if a blood test is a right move.
It’s interesting when you describe all of this. It’s like déjà vu for me. When I go to my provider and sit with them, they lead the conversation. I don’t have to think about it a whole lot like, “Should I get tested this or not this? Do I get on PrEP? Do I not? When I was in a relationship, we were monogamous. I’m not on PrEP.” She says, “Don’t risk your kidney or liver,” whatever the thing was. I forget the conversation we had but she goes, “Let’s talk about this and that.” It’s an easy conversation to have.
Sometimes they’re not there, whoever it is. I went to three different people in a year because every time I got someone I liked, they moved on to somewhere else. The conversation was the same almost with everybody. It’s very fluid and maybe it’s because I was more open to it and I said, “Let’s talk about these things and tell me what I don’t know.” I’m not a medical expert. I don’t know what’s floating around out there sometimes. I want people to tell me and ask a lot of awesome questions about what my life is going on and what I’m doing in it.
I’ll only add one thing. From my experiences, non-judgmental people are worried about being judged. There is no judgment. These folks are there to support you and they’re professionals. It may be difficult for you to talk because sometimes, they’ll ask you questions about your behaviors and so on. It might be difficult to disclose things but that person’s not sitting there going, “They’re there to help.”
Not at all. We want the information so we can make the best recommendations.
They do ask personal questions like your sexual positions, preference or the types of sex you have. “Are you oral only? Do you do anal?” Some people might be embarrassed to talk about that and they shouldn’t be. To your point, some people are and I’ve encouraged them to find a way around that to talk to their professional.
It’s in your best interest, to be honest.
I don’t know to swab your rectum if you don’t tell me that you have anal sex.
Let’s talk about oral herpes, HSV-1, since we’re on the herpes kick. That was second to last. It was very low challenge on the risk and in part.
The variants are the same on those as well.
I don’t remember. I’m curious. I don’t have the data in front of me.
I’m impressed, Greg, with you using that science term. It rolled off your tongue easily, variants.
I want to know what men say and what women say. There’s a little bit different in that. I don’t think White straight men get tested as much as others.
They’re too confident. This is super common. Most people have HSV-1.
The estimate is 50% to 80% of the population.
Is there any treatment for it?
Yes, I’m glad you asked because it’s an STI that’s super manageable. There’s a medication that you can use to treat an active outbreak when you’re having a sore and blister to the mouth or genitals. This is important to say for both that you can treat episodically when you’re having an outbreak and use suppressive treatment. Suppression is an antiviral that you take once a day that reduces the frequency and the severity of your outbreaks.
If you have a partner who you don’t want to transmit to or you don’t want to experience a lot of outbreaks, it’s a low-risk medication. You can take it daily and lower your risk of transmitting by about half. They only did these studies with heterosexual partners for over a year. They found that when a partner takes suppression, a man can reduce transmission to his partner. It’s 10%. Out of 100 couples, ten of the men will transmit to the woman if they’re not doing anything over a year.
You can reduce that to 5% if you take suppression and you can reduce that to 2.5% if you use condoms and suppression. Women are less likely to transmit to men. It’s 5 out of 100 with nothing and then 2.5% you can go down to if you use suppression and half of that. I can’t do that math 1.25% with suppression and condoms. It’s a great way to manage and reduce transmission.
Correct me if I’m wrong. I have a buddy who every so often gets a canker sore on his lip in the same spot. He chills out sexually during that time. He has a long-term partner. That’s his model.
It’s a good model because that is the time when you’re most contagious when you have an active outbreak and it’s transmitted through skin-to-skin contact with mucosal tissue or tissue that’s perigenital. Some people do get on their thighs and buttocks on outbreaks. If that comes into contact with vulnerable skin, whether it’s the mouth, the inside of the nose or the genital area, you can transmit.
When there’s an active outbreak, that’s the most contagious time. However, it’s important to know that there’s also asymptomatic viral shedding. There can be a virus on the skin for someone who’s HSV positive 1 or 2. They don’t know their shedding virus and you can transmit it during those times. It’s more difficult to transmit during those times. You’re not always going to transmit during those times but it’s possible. It’s good to know what all the possibilities are. It’s quite a low risk during those times but it’s not zero risk.
One other question. People who have HSV1, is it true that they didn’t necessarily get it through intimate contact?
It could be when a relative kissed you hello when you were a little kid.
That’s happened to me. I hadn’t had a cold sore, as we called them, when I was growing up. I have baby pictures with a cold sore. I wasn’t walking yet. I was still in the crib and everything. I would get them when under stress. The doctor prescribed a medication for me when they would come up and I started to get that itch. I haven’t had them in years. That’s still carrying it.
It never goes away. It can lie dormant for years without ever manifesting in any way. It can be transmitted anytime during those years if there’s asymptomatic shedding going on and you have intimate contact or you kiss somebody during that time. It’s a tough one. Here’s an interesting factoid or pearl that I’m going to drop here. One of the reasons why it’s been difficult to come up with a vaccine for HSV is because it would be great.
There’s a lot of money to be made in that vaccine.
HSV lives in the nervous system. It makes its way into the nerves and lives there. It’s hard for a vaccine to penetrate that deeply into nerve tissue to be effective.
If you’re stressed, that’s why it comes up more sick or something.
That’s a good theory. I’m not 100% sure about that but an outbreak can be brought on by stress.
Let’s do the last two and we’re going to wrap up with some best practices here. The last two are gonorrhea and chlamydia. Chlamydia was the least challenging on the list and gonorrhea was after genital herpes. It was in the middle there. I was a little surprised by that. I was like, “Is it because gonorrhea sounds scarier than chlamydia?” It sounds like a scarier word. Is there something that these folks are accurate in terms of their rankings?
Maybe because what’s happened is when we test for chlamydia, we test for gonorrhea. We barely separate them.
They feel like they’re brother and sister.
It’s almost one word. They’re different bacteria and treated differently. They manifest very similarly. Gonorrhea more often causes symptoms in men. It doesn’t cause symptoms very much in women. Chlamydia is more often asymptomatic in both but can show symptoms in both. I’m saying the probabilities and the likelihoods here and know everybody that there are exceptions to all of us.
Chlamydia is slightly more common. In 2018, there were 1.8 million reported chlamydia infections in the US and 1.6 million gonorrhea infections. They’re neck and neck. For gonorrhea, you have to get a shot to treat it with an antibiotic called ceftriaxone. Maybe because you need a shot as opposed to oral treatment. That could be why people are putting it higher.
Gonorrhea sounds worse.
They both sound terrible. Herpes is the one that sounds the least aggravating and the one that scares people the most.
It does more often cause symptoms in men than chlamydia. It’s possible, that’s why. They both have the same likelihood that they can cause problems that I talked about before if they’re left untreated. In chlamydia, the treatment used to be a one-time pill of azithromycin and then we’ve upped it to doxy because we found that doxy is better at treating. That’s a week-long thing. Maybe because you could take one pill for chlamydia for a long time and you were done. It could be for that reason that people perceive gonorrhea as worse.
The treatment of this is pretty straightforward and highly effective. You can often do the treatments if you’ve been informed that you’ve been exposed.
You can do treatment and testing. You have to get in touch with your provider. Here are a couple of things to notice. If you get gonorrhea in your throat, it’s harder to clear. You should be tested fourteen days later. We call that a test of cure to make sure. I’m putting this out there. Make sure your provider retests you in two weeks if you have pharyngeal gonorrhea.
It’s impossible not to talk about testing and put it off. This goes back to, “I want to feel clean,” a feeling that’s not accurate. When someone has COVID, they keep testing. I don’t have it anymore but my understanding is that’s not.
There’s a recommended way to do that. Let’s say you got tested for gonorrhea and chlamydia but you weren’t tested for syphilis or HIV. The next thing your provider should do is say, “We want you to come in and test you for HIV and syphilis because sometimes STDs go hand in hand.” You should retest in three months after a positive diagnosis because reinfection is common. We like to do that. If it’s pharyngeal gonorrhea, you should be testing in two weeks. That’s the throat.
If you want to get tested sooner than three months because it’s causing you anxiety, that’s fine but you should wait at least three weeks. We’ll test you anytime but you should know that insurance might not cover it if you’re testing too soon. You should check with your insurance company if you’re relying on insurance. You should know that testing can pick up dead bits of chlamydia and gonorrhea and register a positive, even if treatment was effective for about three weeks after you get treated. Be careful not to cause yourself because people want to test and test.
Retest as much as you want to feel comfortable but try not to drive yourself crazy, knowing these things. Your provider should be telling you this. It’s good to know that you can do Expedited Partner Therapy, EPT. If you get diagnosed and you have any partners who you’ve been with and who are unlikely to seek treatment or testing, your provider should be able to provide treatment. Depending on the state they live in and philosophy, you can at least ask for treatment for 1 to 2 partners.
I’m glad you said that. They’ll ask me that as well. That’s something I had no idea about that the doctor mentioned it to me. Isn’t that nice to know? You walk out with extra medication for somebody.
We need their name, allergies and date of birth. My practice where I work will do it.
In terms of testing, we’ve discussed some of those places. Your general practitioner is a place like Planned Parenthood, a clinic. I have discovered that you can do mail-in tests. Greg, it’s nice to hear you say, “It’s almost like a drive-thru.” My experience at Planned Parenthood, while I’m supportive of it, was like, “We can give you an appointment two weeks from now.” It’s another eight days before you’re going to get your results and so on. There are certain situations where you’re like, “I’m thinking eight minutes.” The nice thing about the tests is, first of all, you can have them on hand. You go online, activate them and put them in the mail. 5 to 7 days later, you get your results.
You make a great point about accessibility, timeliness and testing. This is what I want to ask you about these home tests. Do you pee in a cup or do you have to swab yourself?
You pee in a cup.
I have less of a problem with the home tests. That’s funny sending pee through the mail.
It’s in a vial. It’s closed in a bag.
I worry about user error in general when someone’s doing a self-test.
If someone’s looking for a free business idea, you could create any home testing that’s easy to follow with large font. It’s written by practitioners who are cursed with knowledge. You need a good UX designer to deal with these things. That is a bit of a point of pain with them.
I do worry about that because I know that. It’s hard to follow.
It’s not that hard but it’s unpleasant. You have to concentrate.
You have to lay it out on the table and go through steps 1, 2 and 3. For women, self-swabbing is not that hard because putting a Q-tip into your vagina is not a big deal. It’s not painful. For the guys, the instructions are to take a swab and insert it 2 to 3 centimeters into your urethra and twist it around 3 times. I don’t know any guy who’s going to be happy to do that unless someone is breathing down their neck watching, “You got to twist it one more time.” I feel better about that. If something’s more accessible and timely, I’m all in favor of that.
I’d also like it if someone has a little bit of shame behind it. They can do it behind closed doors. I grew up in a very small community and I wouldn’t want to go buy condoms or pornographic magazines because the whole town knows. All 400 people in town know everything’s happening. You think the same thing about your medical providers. We are going to tell my business and things of that nature.
If you’ve got a sixteen-year-old that’s sexually active and their parents don’t know, things like this are awesome on how they get them mailed to them. I don’t know how they would get around that. I like the idea that people can do it. Something is better than nothing is what I’m trying to say. Especially if you’re in a rural place, you can’t get to facilities very easily. Anything helps. Doing it in person is much more valuable to me as an active person.
You’re going to have these conversations that Jill’s been talking about where you can create a bespoke set of tests.
We’re not creating a whole generation of Google doctors. We’re always like, “I’ve got this symptom. I’m going to go google it.” The next thing you know, we’re fatalistic about things. To Jill’s point, the stuff is all treatable and manageable. We’ll upset ourselves a lot more than we’d be.
Speaking of Google, it’s a great place to get a lot of information but suppose you have a partner tell you, “I’ve had a gonorrhea diagnosis,” and you turn to Google, it can create a very scary place. It can feel like a judging thing where you’re like, “I shouldn’t have done this. I’m a bad person.”
You can spin out on it.
Seeing a provider and going to a clinic, the problem with the home tests are you’re not having this conversation. At least you are if you’re going to come back with a positive. The company is going to contact and counsel you but where are good places online where you can get a more balanced conversation like this one?
ASHA is fantastic, American Sexual Health Association. They have a fantastic website. The STI Project, I love that website because they speak to exactly what you’re talking about, which is the societal shame, blame and negative stigma that can be attached to STIs that can play into any insecurity that you might already have about yourself. We all have insecurities. You put this on top of it and it’s a way to fuel the fire to catastrophize the situation. To spin out and roll down the hill, “Who’s going to love me now? How am I ever going to have sex again?”
Also, “How do I tell other partners?” There’s this cascading effect of behavior and urgency.
The STI Project is freely, nicely, calmly, logically, rationally and while acknowledging the emotions, addresses these concerns, also dealing with the reality of the situation. Bad things can happen if STIs aren’t treated but we know about it so we’re going to treat them. Let’s not go there. Let’s talk about how we can feel okay and still feel like the valuable good person that we are who experienced some bad luck and caught an infection. It’s a deal but it’s not a huge catastrophe or tragic deal.
If anyone out there who’s reading this is feeling that way, I would recommend checking out the STI Project and ASHA. Talk to a trusted friend who they feel comfortable with. Let’s say I’m speaking to you. You’re out there feeling bad. It’s understandable why you’re there but you don’t have to stay here. If you’re Greg and your doctor, nurse practitioner or PA can get you to a better place, go for it because you can have this issue that you’re having and get to a better place.
Let’s finish by talking about some best practices and you can do this at the personal level or professional level. I’ll raise a couple of topics and let you weigh in. I have a reader’s comment, best practices with regard to discussing these disclosure expectations, lower risks behavior, perhaps. I’m going to offer one about condoms. This was a member of the Solo community, which you can sign up for at PeterMcGraw.org/Solo.
She writes, “The area I’m interested in is what is the best time to address condoms with a new lover. Timing is everything here. Too early can seem presumptuous but leaving it to the ‘last minute’ creates the most awkward and disruptive break in the flow. Is there anyone out there who is smooth at this and who has found flow and timing that works? A best practice I developed. I don’t agree to go to someone’s home after a date whom I met for a nightcap unless, A) I know I may be interested in sex and, B) I have protection with me. This is after too many difficult moments. Agreeing to go to someone’s house is often taken as a signal. I’m careful about the signals I send.”
It takes away. It’s not as sexy to say to have that conversation like the movies. “We’re spontaneous having a great night.” It’s raining and they’re like, “Come on in.” I don’t know if there’s ever a great time to talk about it. Going back to the upset in the homosexual community, it says, “Do you use condoms? Do you not? What is your preference?”
You can be a behind-the-scenes warrior on that. You don’t have to put yourself out there and be vulnerable in a conversation. You could say, “As I said in my app, I use condoms.” Remind people so you don’t have to broach that randomly over the first glass of wine like, “This is going well.” Everybody should take protection with them and always presume that they need to have that.
I once left a bedroom, put my clothes back on, went down to my car and was rooting around the trunk in my bag for a fresh condom to bring back up the stairs because there wasn’t one available. I’m glad I had it.
To your reader who wrote the questions, I don’t think it’s presumptuous to have condoms with you and around. We always keep water in our cars, snow shoveling and bad weather. You have to be prepared. Sometimes, spontaneity is awesome and you want to be able to enjoy that moment if you’re feeling it. It doesn’t have to be, “We’re going to schedule this three weeks out. I can get everything I need and be done.” Always be prepared. I’m not saying put it in your wallet like we used to do in high school but have them available.
Have your EpiPen in case there’s a bee flying around.
It’s less awkward to talk about these things. Once you get in the habit of talking about sex before you are having sex and I can say this as a man, it’s much more liberating to know what can happen, what can’t happen and how it should go down in a way that you feel comfortable and thus able to be fully present, know there’s consent and know these things that are there.
For the reader who wrote in, I love that she’s thinking about these things and figuring out what her best practices are. One of the things I wrote down on my list of risk reduction is thinking ahead. Being prepared for that when you get into the moments can feel more flowy and spontaneous because you’re ready. You’ve got something in your back pocket.
The other thing I would say though is your sex is probably going to go the range from comedic and hilarious to flowy and sensual, like the cover of a Harlequin romance novel like, “I have had sex and we lit a candle. The shadows in the room were sexy. The pillow got on fire.” All of a sudden, it’s like, “What is going on? There’s a fire in the room.” The adrenaline was pumping but not in a great way. It was because I thought my house was going to burn down. It’s a great story. Sometimes sex is messy, awkward and funny. That’s going to be some of the experiences that we have sexually. We have to work that into the repertoire of how it might go sometimes. Sometimes, it’ll be beautiful.
It’s like, “How do you learn words to a song?” You listen to it, repeat it and sing it a lot. When you have something that might be awkward for you to say or speak about, keep repeating it and saying it until you almost memorize it. It becomes a script for all that. That’s an awesome thing to do. We’re like, “I’ll talk about it when I have to.” They put it off and make them uncomfortable. If you know what you’re going to say, you own it and you have that confidence, that’s a sexy thing in itself. When a woman walks into your bedroom and was like, “This is what we’re going to do and how we’re going to do it,” you’re like, “I don’t have to think about it. This is awesome.”
I’m glad you mentioned it because these websites Planned Parenthood, ASHA and The STI project have scripts. You can print something out. You can read it, rehearse it and practice it with a friend. Here’s another thing that’s important to mention. This is a conversation. It’s not someone admitting something shameful. It’s a dialogue between two people. At any given dialogue, you might be on one end of the conversation.
For example, someone might be disclosed to you that they have an STI, you might be disclosing it to someone else or it could be both. I love the idea that there are scripts to prepare for that because they also help prepare. As a human being on this planet in a community of people, when you hear from someone else that they have an STI and how to receive that information in a respectful, kind way or whatever your response is, you might want to say, “I need to look into that more. I want to talk to my practitioner about it. Can we take it slowly? No, I’m not comfortable with that but thank you so much for telling me.” Any of those are okay but do it nicely because it takes so much courage.
I have a friend with herpes and she has that information. She will send it to new partners if they’re asking. Probably about 70% of the time, from what I’ve been told, the other person says, “Me too.” It’s that uncommon. You think you’re the only one on that mountain top of this STI or something to say. The person you’re telling half the time could be in the same situation.
She has all this information and she will send it to them. She’s like, “Do your research, figure it out and let me know what you’re comfortable with.” I like how she owns that. She’s taken it upon herself to educate people and do it early because she’s sexually active. She’s not going to wait three months. She could but she doesn’t want to. She wants everyone to be comfortable. It makes your time working together more fun.
The person who responds well to that, they’re going to be a good partner and have a nice connection. The person who’s not comfortable with that goes away.
I want to bring up three quick ones. The first one is to call back to the condom thing. I had an experience with a woman who said, “I always use condoms.” I said, “No problem.” It was funny because she brought condoms and we had the same condoms. She’s like, “You have good taste in condoms.” The issue is things have changed since the days of having a Trojan in your wallet. There are different types. There are latex and non-latex. There are a whole bunch of different options out there.
One of the things that you can always do is you can say, “These are the condoms I prefer,” especially as a woman in that situation. There’s like, “Why would there be any stigma of having this?” It’s like, “These are the ones that I prefer in that sense.” In terms of talking to people, there’s a sweet spot. The presumptuous comment that this reader made is real. She like, “We’re getting to know each other. I’m not sure I even want to kiss you.” Sometimes there’s arousal. There’s research on this. People make compromises when they’re highly aroused or drunk. You want to find that spot where it’s comfortable to talk about what the expectations and tests are.
When it comes to talking about these things, they are like, “When were you last tested? What were you tested for? What was the outcome? What has your partner’s situation been like?” Perhaps also birth control-related to conversations that ought to be had to decide on not only what protection gets used but what acts get initiated. One of the things I want to say and remind people is we’ve been talking about sex. There’s a tendency that there’s this one sex act that matters depending on your orientation and that doesn’t have to be the case.
In terms of heterosexual couples having intercourse is this big thing. You can get close, aroused and satisfied doing a whole variety of things that don’t involve any intercourse at all. A good old-school throwback make-out session can be a wonderful way to get to know someone and enjoy someone’s company. Just because everything doesn’t match up doesn’t mean like, “We can’t see each other, be intimate and enjoy the pleasures of the flesh.” There’s a lot of flesh. It’s their body besides their genitals. That’s like my friendly PSA out there.
There doesn’t have to be insertion to have a good time with somebody. A lot of things can happen like oral, kissing, touching and manual stimulation with each other. There are many things you can do if it gets to that point and that way, you don’t veer off your course of what you want to do or not do. If you start drinking, your inhibitions go away. Have it in your head like, “I don’t drive drunk. I don’t go home with people when I’m drunk.”
That’s a great way to look at it. I don’t have the STI conversation when I’m drunk. What the studies show is that people who want to use a certain level of protection want to protect their partner and themselves. They don’t if the drunkenness or the intimacy gets revved up before they’ve had the conversation. Even if you want to protect yourself and your partner, you don’t in those situations.
The vast majority of people are meeting online and you can be a little keyboard warrior about those things. Have your script that you’re talking about. You could say, “If it gets to this point, these are my boundaries.” You can do that. You don’t even have to be face to face so much anymore. You can get it out there if you need little easier.
The best sexual and sensual partners are going to be the people who react and behave best in these scenarios. I don’t want to say it’s a litmus test but if you find that a person receives this information well, volunteers this information and initiates these kinds of things, it means not only they’re comfortable but they’re likely to be a good lover to you in a lot of ways.
It’s kindness or respect that comes from listening and disclosing. There’s certain care that you demonstrate.
I want to turn this into a parting thought from our person with her boots on the ground and our man in the streets, a man in the sheets, Greg. This is longer than a typical episode. I’m going to keep it as one. It’s important. Reflecting on what we’ve talked about, is there something for the person who’s stuck with us to the end that you want them to walk away with or reiterate?
I don’t want anyone to have shame about it. We need to own that, be respectful of that, honor it and require the same thing from our sexual partners. There doesn’t need to be shame around it at all. That’s my big thing. Talk about it and open it up. I want people to talk about things like, “I’ve had COVID.” Anything that’s bad take away the stigma from things. That’s my only thing. Own it. It’s not a big deal.
In this episode, we’ve covered so much and it also feels like the tip of the iceberg. There’s so much more. If this brought more questions for you, I would say, “Go seek the answers because they’re out there.” Not with a Google search. Use the resources that we’ve mentioned here or your healthcare provider because you might have more questions after this.
To finish up this last thread on disclosure, depending on where you feel comfortable as a person with this other person determines when you can disclose anything about yourself. Including your STI status, the important thing is to do it before you share a risky activity with them. It can be when you’ve known them for a day, a week or a month. It should be before you potentially expose them to the risk of transmission because you are being the kind and respectful partner who cares about having and enjoying sex but also reducing harm and preventing transmission of disease. That’s the one I’ll finish on because I’m the nurse. I had to do something clinical.
Thank you to both of you.
- What Makes a Life Remarkable – Past Episode
- How To Go on a Date? – Past Episode
- Defining Spaces
- Herpes: The New Sexual Leprosy
- Planned Parenthood
- The STI Project
About Jill Cohen
Jill Cohen grew up in Miami, attended Emory University, received a masters in English from the University of Colorado and currently resides in Boulder. As a travelling ER and a tele nurse, she worked in Colorado, Wyoming, California, Florida, and Australia. She is a frequent contributor to Solo, including episodes: What Makes a Life Remarkable and How to go on a Date.
About Greg Burns
Greg Burns is the CEO and Founder of Defining Spaces a one-stop-shop for real estate agents’ listing needs. A Hoosier by birth and a Sandlapper by relocation, he received his undergraduate degree from Winthrop University in South Carolina and did his post graduate work in New York City. Greg now lives in Denver with his pug, Cornelius Pugsley.