Decade of the Plague

The Sociopsychological Ramifications of Sexually Transmitted Diseases

Margaret R Rodway, Marianne Wright

• Editorial: Routledge
• Año: 2014
• ISBN:
  9781317714224
• Edición: 1
• Categoría: Medicine
• Categoría: Medical Theory, Practice & Reference

Social workers, counselors, and health care professionals will be challenged by this thorough presentation of Sexually Transmitted Diseases (STDs). The contributing authors contend that in the immediate future, education, not medicine will be the single most important weapon in stemming the spread of STDs. Thus, the responsibility of educating society and providing service for people who are directly or indirectly affected by STDs lies with helping professions. The devastating social, medical, and psychological aspects of AIDS, herpes, and other STDs are discussed. Contributors focus on the issues involved with counseling individuals with STDs--and their partners, families, and friends--and make suggestions for the education and teaching of professionals and the general public about STDs.

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PART I: SOCIAL, PSYCHOLOGICAL AND MEDICAL DIMENSIONS

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Sexually Transmitted Diseases — An Overview

Barbara Romanowski
Gillian Piper

INTRODUCTION

During the last five years sexually transmitted diseases (STD) have been the focus of many sensational articles in the popular press. The appearance of acquired immunodeficiency syndrome (AIDS) in 1981 and the increasing incidence of other STD worldwide has stimulated further interest in both the general public and the helping professions. The term STD has replaced the traditional “venereal diseases” (VD) which historically have included gonorrhea, syphilis, chancroid, lymphogranuloma venereum and granuloma inguinale. STD are diseases for which sexual contact is epidemiologically significant, but need not be the only mode of acquisition. Table 1 provides a list of STD. In 1984, traditional venereal diseases accounted for greater than 50% of all notifiable diseases in Canada. Although the incidence of gonorrhea has declined over the past decade, non-gonococcalurethritis (NGU) in men and mucopurulent Cervicitis (MPC) in women has increased in equal proportions and now outnumbers gonorrhea by a ratio of at least 1.5:1. Furthermore the morbidity and mortality associated with NGU/MPC equals or exceeds that of gonorrhea.

Table 1
Etiological Classification of Sexually Transmitted Diseases

Bacterial

Non-gonococcal urethritis/mucopurulent Cervicitis

Gonorrhea

Pelvic Inflammatory Disease

Bacterial vaginosis

Syphilis

Chancroid

Granuloma inguinale

Lymphogranuloma venereum

Viral

Herpes genitalis

Genital warts

Molluscum contagiosum

Hepatitis B

Acquired Immunodeficiency Syndrome

Cytomegalovirus Infections

Fungal

Vulvovaginitis (Candida albicans)

Protozoal

Vaginitis (Trichomonas vaginalis)

Ectoparasites

Pediculosis pubis (crab louse)

Scabies

Factors associated with the increasing incidence of STD include the availability of multiple sexual partners, asymptomatic disease, a highly mobile society, increasing affluence and leisure time, alcohol consumption, and variable standards in diagnosis and management. The sequelae of these infections are particularly important as they relate to maternal and infant morbidity, reproduction and fertility. For example, pelvic inflammatory disease (PID) following either mucopurulent Cervicitis or gonorrhea can lead to infertility, fetal loss or infant death. Exposure to human papilloma virus (genital warts) or herpes simplex infection has been linked to the development of cancer of the cervix in women.

STD may affect any individual regardless of sex, race or socio-economic status. Pre-pubertal children with a sexually transmitted disease should be assumed to have been sexually abused until proven otherwise.

The psychological impact of infection with an STD is often overshadowed by the medical condition. Many individuals delay attending a clinic or physician's office for diagnosis and treatment because of fear, embarrassment or guilt. Unfortunately many health care providers are equally ill at ease with STD and their interaction with the patient/client may be colored by strong feelings of disapproval or frank hostility.

Suitable management of sexually transmitted infections is dependent on the information obtained in the medical history. An individual's sexual preference and practices must be discerned as well as a history of homosexual, bisexual or heterosexual contact. This information should be acquired in a straightforward, non-judgemental fashion.

The remainder of this article deals with the most common sexually transmitted diseases. It is an attempt to supply some necessary medical information in order that appropriate sociological and psychological guidance and support can be provided to the client/patient with an STD.

NON-GONOCOCCAL URETHRITIS/MUCOPURULENT CERVICITIS (NGU/MPC)

NGU/MPC is the most common sexually transmitted disease in North America. Although the signs and symptoms of this infection are similar to that of gonorrhea the organism causing the infection is not gonorrhea and hence the term “non-gonococcal.” Chlamydia trachomatis will be the cause of the infection in 40% to 60% of cases of NGU/MPC (Bell & Gripton, 1986). The etiology of the remaining cases is, as yet, not well defined.

The incubation period (the time between infection and the appearance of symptoms) for NGU/MPC is usually 7 to 35 days with the average being 14 to 21 days after sexual contact with an infected partner. A significant proportion of men and an extremely large proportion of women may have this infection but remain asymptomatic. These individuals can still spread the infection to their sexual partners.

The symptoms of NGU in the male are most commonly Urethritis (urethral discharge) and dysuria (pain on voiding). The urethral discharge is usually less profuse and less purulent than that experienced with gonorrhea. These symptoms are sometimes only evident in the morning and the discharge can be so slight that the only recognized sign is crusting at the opening to the urinary tract.

The disease in women analogous to NGU is called mucopurulent Cervicitis because the infecting organisms cause irritation of the cervix resulting in redness, swelling and an abnormal discharge (Brunham et al., 1984). Chlamydia can also infect the rectum and throat in both males and females.

Many women do not manifest any symptoms of mucopurulent Cervicitis which often delays its diagnosis and treatment. The longer the infection remains untreated, the greater the chances are of progression to complications such as pelvic inflammatory disease. Locating and treating sexual partners of these women is an extremely important facet to the control and appropriate medical management of STD.

Non-gonococcal Urethritis is diagnosed on the basis of a simple laboratory test which can be performed in a doctor's office. A sample of the urethral discharge is examined under the microscope to look for evidence of pus cells. In order to identify the organism causing the infection a further specimen of the discharge may be sent to the laboratory for culture. Similarly, MPC is diagnosed by examining the cervix for visual evidence of infection and then submitting a sample of the discharge for culture. However a culture is not mandatory in order to make a diagnosis of NGU.

Complications can occur if an individual is not treated promptly. In the male these complications include epididymitis (inflammation of the ducts which provide storage, transportation and maturation of sperm), Prostatitis, and Reiter's syndrome which is a tetrad consisting of arthritis, Urethritis, dermatitis and conjunctivitis. Females may develop acute Salpingitis (inflammation of the fallopian tubes) leading to permanent tubal damage, ectopic (tubal) pregnancy, chronic pelvic pain, dysmenorrhea (painful menstruation), dyspareunia (painful sexual intercourse) and psychological morbidity. One woman in five, age 25 to 34, will become infertile after one confirmed case of Salpingitis. After two to three episodes of Salpingitis, 31% to 60% respectively, will become infertile (Westrom, 1980).

The final complications which must be addressed occur in infants born to infected mothers. These infants are at high risk of developing both conjunctivitis and a distinctive chlamydial pneumonia. Installation of erythromycin or tetracycline eye drops at the time of delivery will, in most cases, prevent conjunctivitis but will have no effect on the development of pneumonia. It is extremely important to check for Chlamydia in pregnant women at high risk of acquiring this infection.

Non-gonococcal urethritis/mucopurulent Cervicitis is a relatively easy infection to treat with antibiotics. The dosage and duration of therapy is somewhat variable depending on the specific drug utilized. It is of course important for the patient not only to take the medications properly but also to abstain from sexual contact until a test of cure has been carried out and finally to ensure treatment of his or her sexual partners.

GONORRHEA

Gonorrhea is an infection caused by the bacteria Neisseria gonorrhoeae. The disease is almost always sexually transmitted.

The groups at highest risk of gonorrhea are males age 20 to 24 years followed by females age 15 to 19 years. Males 15 to 19 years and females 20 to 24 years follow sequentially.

The clinical picture of the disease is varied with many individuals being asymptomatic. Only 20% to 50% of women with a genital infection will have symptoms (Hook & Holmes, 1985). The symptoms may be as slight as a change in the normal vaginal discharge but may also include dysuria, bleeding between menstrual periods or pain and swelling of the glands situated at the vaginal opening. Symptoms generally appear two to ten days after contact with an infected partner.

The most common complication of genital gonorrhea in women is pelvic inflammatory disease. The bacteria ascends from the cervix into the uterus and from there spreads to the fallopian tubes and ovaries. The sequelae of PID is often sterility or ectopic pregnancy due to scarring of the fallopian tubes thereby interfering with passage of the ova to the uterus.

Anorectal gonococcal infections in women are not uncommon and are in most instances, due to contiguous spread of infection from the vagina rather than occurring as a result of penile-anal intercourse. This type of infection is most frequently asymptomatic.

Orogenital contact can also transmit the infection. It is acquired more effectively by fellatio than cunnilingus, therefore proportionally more women and gay men will contract a pharyngeal infection. Again the majority of these infections are asymptomatic.

The vast majority of men who acquire gonococcal infections have symptoms with only 3% to 10% remaining asymptomatic. Presenting symptoms include an abrupt onset of dysuria and purulent urethral discharge.

The most common complication of untreated gonorrhea in men is acute epididymitis with pain and swelling of the testes. Damage to the epididymis can result in sterility. Other complications include infection of the prostate gland and the lymph nodes surrounding the penis.

The diagnosis of gonorrhea is made on the basis of laboratory tests in the same way as previously described for NGU/MPC. Early treatment with antibiotics is effective at both eradicating the disease and preventing complications from occurring. Once again it is extremely important that sexual partners be identified and offered appropriate treatment.

GONORRHEA IN CHILDREN

Genital gonorrhea in children should be considered the result of sexual abuse until there is definitive proof to the contrary. Research has consistently demonstrated the very infrequent transmission by means other than some type of sexual contact (Neinstein et al., 1984). Neonates born to mothers with untreated gonorrhea may develop conjunctivitis which is associated with serious complications if not recognized and treated early. Again the instillation of antibiotic eye drops at the time of delivery usually prevents this complication from occurring.

VAGINITIS

Vaginal infections are common in adult women. The three organisms most frequently found are Candida albicans, Trichomonas vaginalis, and Gardnerella vaginalis (Bowie, 1983). Infections of the vagina cause inflammation, abnormal vaginal discharge and genital itching.

Candidiasis or yeast infection is caused by a fungus — usually Candida albicans. Females rarely acquire this infection through sexual contact. However, women may transmit the infection to their partners resulting in an inflammation of the glans penis. Factors making women more susceptible to this infection include pregnancy, antibiotic therapy, oral contraceptive use, menstruation, diabetes mellitus and immunosuppression. Nylon underwear and pantyhose may also be contributing factors as they increase the temperature and humidity of the perineum. Following clinical/laboratory investigation to determine the causative organism, candidiasis is treated with vaginal application of antifungal creams. Unfortunately, there is a tendency for the infection to recur following treatment.

Trichomonas vaginalis (a parasite) is acquired during sexual contact with an infected individual while Gardnerella vaginalis (a bacteria) is rarely sexually transmitted. Both infections are manifest by an abnormal vaginal discharge, inflammation and irritation of the genital area. The discharge associated with gardnerella, tends to be slight in amount and malodorous, while that of trichomonas is profuse, purulent and frothy.

Diagnosis is made through clinical and laboratory examination. Treatment with vaginal creams and/or oral medication is usually effective. The regular male partner of an infected woman is often treated to prevent re-infection of the female partner.

GENITAL HERPES

The most common cause of genital sores in North America is infection by the Herpes Simplex virus (HSV). This virus is responsible not only for genital lesions but also for cold sores around the mouth. HSV is divided into two types, HSV I most often isolated from lesions around the mouth and HSV II isolated from the genital area (Corey et al., 1983). However, both types can and do infect all anatomical sites.

Transmission of the virus is by direct contact with an infected area of the body. The transmission most frequently occurs during sexual intercourse. However, it can occu...