I don’t always agree with the Randy Cohen’s advice in The Ethicist column in the New York Times magazine, but this week he got it right. In advising a 61 year old man that he did not neeed to share his prior history of treated gonorrhea with potential girlfriends, Randy said this –
…Contracting an S.T.D. is not a misdeed, not a moral failing, not an indication of your character; it’s a medical problem.
Well said, Randy. Except the new acronym is STI – Sexually Transmitted Infection. A more appropriate word than disease, especially for infections that for the most part, are transient and treatable.
We don’t pass judgement on one another when we give each other colds, the flu and strep throat. Let’s stop doing so when we give one another STI’s. These infections are after all, just the end result of a virus or bacteria looking for a mucus membrane to invade.
Sometimes, however, getting an STI can be a wake up call that it’s time to limit your number of sexual partners. That’s not necessarily a moral judgement – it’s simple mathematics. For some women, having to deal with an STD that resulted from a one night stand or an encounter with someone whose feelings for you are unclear is much more difficult than having acquired an STI from someone who really cares about you and who you also love. Again, this is not a moral judgement. Just something I’ve learned from treating many women over the years who have had STI’s.
You clearly deserve the top doc honors. I moved to a new state and set about finding a new gyno. I chose a man who had a phenomenal reputation. I thought I was incredibly lucky to get an appointment with him–so quickly too. All was well until we sat down in his office afterwards. I had been battling trich–it just wouldn’t go away.
That man set about crawling into his pulpit and giving me the most humiliating moral sermon. I left in tears and NEVER went back to him.
Bless you for not judging.
If I were a doc, I would have your perspective too. But as married guy, it wouldn’t fly for my wife and I…for obvious reasons!
While you say that many STIs are transient and treatable, aren’t there long-term implications for women for having had these infections? Syphilis untreated can permanently damage internal organs, including the brain. Chlamydia and gonorrhea in men can cause enough urethral scarring to cause painful urination and other urinary complications. Herpes can be life altering for many…not to mention that women of today have enough trouble conceiving. Don’t many STIs contribute to difficult conception?
To me it seems that these infections are a bit more severe in lifestyle impact as opposed to strep throat or bronchitis. In addtion, the patient is tracked by the governement, which has got to be disconcerting to say the least. Hopefully these are the best kept secrets in the government. The premise of being tracked is so invasive.
(sidebar: Why does the health department want to know about some STIs but not others?)
I hope that anyone who is in the circumstances to need treatment finds a provider that is there for the medical need, and has no judgement. But I also hope that we educate our youngsters in particular, that these are not infections that are immaterial either.
To me, human sexuality is too complex to leave STIs at a place where “…it’s just an infection”. I feel that are more issues at play for many of those that are in the need of care.
I am surprised that your patients have had more angst over STIs from one night stands than from someone they care about. Doesn’t the sudden question about a relationship they thought was exclusive cause just as much emotional upheaval?
Great post.
I think this type of attitude will spill over into screening all patients equally for STI’s, not just ones that are honest about having multiple sexual partners.
I have been part of a practice and knew someone who worked at another practice where the protocol was to let screenings slide for married women, to a certain extent, but to actively pursue them in unmarried women. Relegating STIs to a special stigmatized category keeps people from getting screened.
Schruggling, this column said that you do not have to disclose a past, treated infection that is gone. It did not say it was OK to not tell a partner about a current infection, let them get infected, and then not advise them to get treated. Of course that would be unethical.
Anonymous – I’m so sorry to hear what you went through. And thanks for your nice comments.
Schrugglin – You are right re the long term issues with some sti’s, but note I said “for the most part”. Most chlamydia infections resolve with treatment, and the last time I say brain damage from syphilis was …well, never. In fact, I think the last case of syphilis I’ve seen was in residency, but then again, that STI tends to reside more in certain high risk groups that I tend not to see in my practice.
Herpes, of course, is forever there, but in reality, extremely easy to control and live with (as a lifelong fever blister sufferer, I know this well…)
We routinely screen for STI’s in pregnancy and treat them before birth for the most part. But other infections can and do also cause problems in pregnancy – toxoplasmosis, chickenpox, Parvovirus to name a few. We don’t stigmatize those, do we? We just go ahead and treat them.
Agree, a new STI in a marriage is not a good thing. But then again, it’s not the STI that is the problem, is it? It’s the activity that led to it.
The DOH wants to know about STI’s that they can treat so that they can track partners,notify them, get them treated and break the chain of infection.
Willard Cates at the CDC used to fantasize about a national zithromax day when line up everyone under 25 for a single 1 gram dose and knocked out this infection once and for all. Not a bad idea. Just finished treating a patient of mine for an ectopic that we presumed resulted from a chlamydia infection in her teens.
My post was not meant to imply that STIs were not serious. They can be. They just don’t make you a bad person.
Bean –
I was thinking of the difference between finding out you got herpes from a one night stand vs getting it from your boyfriend who you care a lot about. Certainly, getting a new STD after being in a committed relationship for a long time may be a marker for infidelity, although that really depends on the STD, doesn’t it? Herpes, for instance, could be transmitted at any point depending upon how often the person sheds the vuirus or has outbreaks.
Hilary –
I tend to screen, not based on marital staus but on sexual history. Which means you have to ask. At every visit, no matter the age or marital status, I ask my patients if they have had any new sexual partners since their last visit with me. If they have, we discuss screening, especially if they or their new partner are under age 25 (the age group where most of the chlamydia tends to reside). Some married women ahve concerns about their partner;s fidelity, and they get screened if they want. I am an equal opportuinity sti screener….
Hillary,
I am in complete agreement about not revealing one’s past to a new partner, and that a current infection is a different circumstance entirely.
TBTAM,
Thanks for the infection management clarification. I will be sure to send a note to my high school health teacher who taught us about the severity of side effects of STIs. She is a great example of selling fear. Perhaps she works in Big Pharma marketing now! It is good to know that you haven’t seen the big syph in years. I guess the increase in syphilis is with men if you aren’t seeing it in your practice? I just keep hearing about the STI rates being on the rise, and more and more resistance to standard treatments. Aren’t the fluoroquinilones no longer recommended for some STIs?
There was a famous murder in my town that occurred when I was 5. A man killed his whole family, moved away and started another life. Turns out he thought his family was possessed by the devil, and that this act of murder was the only way to get them to heaven (he was also severly in debt…). Turns out that the wife had advanced syphilis that was latent for many years, and it was attacking her brain – hence her erractic behavior and his perception that she was possessed. Not sure why he killed the mother and all the kids. It had all of the makings of a Lifetime movie, and in 1993, Robert Blake played him in the movie Judgment Day: The John List Story. So what’s the point? Screen married women for STIs too.
National Z day? Interesting…