Read Our Bodies, Ourselves Online
Authors: Boston Women's Health Book Collective
Our Bodies, Ourselves (61 page)
In general, women are more at risk than men to contract STIs through heterosexual intercourse, simply by design. Any secretions are in contact with the relatively large surface area of the vaginal walls longer then they are in contact with a penis. Furthermore, the vagina is a warm, moist environment, making it an ideal place for viruses, bacteria, and protozoa to multiply.
Adolescent girls have the highest risk because their cervix cells don't produce as much protective cervical fluid as, and are more susceptible to infection than, the adult cervix.
Infections are possible at any age, however, and women who are no longer menstruating may also be at increased risk. In menopause, the vaginal lining gets thinner and often somewhat drier due to decreased production of natural lubricants. Older women can get small breaks in the skin during vaginal intercourse or other penetrative sex, making them vulnerable to sexually transmitted infections. Many health-care providers wrongly assume that older women don't have or don't want sex anymore and are much less likely to give older women STI prevention messages and screening tests. If you are dating again after a long-standing relationship has ended, tell your health care provider about your new sex partner(s).
Regardless of age, try to find a well-informed health-care provider with whom you can talk freely about your sexual health before you have any problems.
If you have sex exclusively with other women, your chance of getting an STI is lower than that of women who have sex with men. However, women in same-sex relationships can be exposed to and transmit STIs, including HPV, HIV, herpes, andâless likelyâchlamydia. The CDC reports that limited data are available on the risk of STIs for women who have sex with women, but risk varies depending on the STI and sexual practice (oral-genital sex; sex involving rubbing genital skin together; vaginal or anal sex using hands, fingers, or penetrative sex toys; and oral-anal sex).
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Many women involved with women either have had or will have sex with men, or may have been raped or have engaged in risky behavior, such as sharing needles or sharing sex toys with partners whose STI status is unknown. Defining risk only in terms of sexual identity can be deceptive; our risk for STI depends on what we do sexually, not how we identify ourselves.
For lesbians, coming out to a health care provider may be difficult. It is important in order to make sure appropriate information, tests, and
treatment are given for STI symptoms. However, even when you explain your sexual orientation, some providers may still have difficulty fully understanding the needs of women who have sex with women:
Recently, I met with a new gynecologist, and I told her I was sexually active with womenâ¦. Later, during the exam, she said we wouldn't need to bother with tests for STIs. I was really surprised. She assumed I couldn't get an STI because my partners are women. Fortunately, I knew that wasn't accurate
.
For more information on coming out to your provider and finding lesbian- or bi-friendly health care, see “Homophobia, Transphobia,
and Heterosexism.”
Women whose genitals have been cut in the practice of female genital cutting (FGC, also referred to as female genital mutilation) have a higher risk of catching an STI from an infected partner because of unhealed ulcers, inflamed vulval membranes, and small sores resulting from intercourse, or having a smaller vaginal opening due to scarring. FGC is also linked with increased rates of pelvic inflammatory disease, among many other complications.
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On average, women have fewer financial resources than men; we are also more likely to be single parents and primary caregivers for those who are ill. For some of us, lack of money can mean lack of access to prevention and treatment. It can also mean we are too preoccupied with our own day-to-day survival, and that of our family members, to pursue safer-sex materials and/or necessary screening and treatment. In these ways, economic injustice contributes to higher rates of untreated STIs, and thus to a higher risk of transmitting STIs among sex partners within communities where poverty is a significant problem.
In cultures that value passivity and submissiveness in women, it can be difficult for a woman to refuse unwanted sex and/or to negotiate condom use. A male partner may refuse to use protection, even if he is having sex with other women or men on the side. For many women, fear of sexual violence and/or financial dependence on a male partner makes negotiating safer sex undesirable or impossible. (See
Chapter 10
, “Safer Sex,” for tips on negotiating condom use.)
Dr. Susan C. Ball, associate professor of medicine at New York Presbyterian Hospital, points out that “the result of this imbalance in sexual power has led to the infection of countless women around the world and of the babies born to them.”
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Many cultures discourage women from touching or looking at their genitals, making it more difficult to notice early signs of an STI. We may also be more sensitive to the shame and stigma associated with having an STI and thus delay diagnosis and treatment.
The insensitivity of some medical institutions to womenâespecially to women of color, poor women, uninsured women, and women who don't speak Englishâresults in many delaying seeking care or testing. Those of us with low incomes and little formal education may find that health-care providers are too quick to suspect that we have an STI, while those of us who seem middle or upper class, or who are married or older, can go through a health visit without the topic coming up at all. Both forms of bias can be damaging.
WHO GETS INFECTED? UNDERSTANDING RACIAL DISPARITIES IN STI OCCURRENCE, PREVENTION, AND CARE
Considering the United States' history of racial discrimination and unequal access to health care, and our national discomfort with race and sexuality, it isn't surprising that sexually transmitted infections take their greatest toll in communities of color. Blame is often put on individual behavior, but the numbers are more likely due to underlying social conditions that our country has failed to confront.
In 2009, African Americans, who account for 12 percent of the population, represented 71 percent of gonorrhea infections and approximately half of all chlamydia and syphilis cases. Overall, their rate of chlamydia was more than eight times that among whites. Young African-American women experienced significantly higher rates of chlamydia and gonorrhea than any other group. Other groups also disproportionately affected are young Hispanic men and women age twenty to twenty-four, whose chlamydia and gonorrhea rates are twice that of whites in the same age group. And among American Indians/Alaska Natives, the rate was more than four times that among whites.
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The incidence of many STIsâespecially HIVâis higher in poor, segregated neighborhoods. These numbers give rise to stereotypes in which women and men from economically disenfranchised communities are portrayed as promiscuous and irresponsible about STI protection. In fact, researchers have found that women in poor African-American communities who engage in the lowest-risk sexual activities are much more likely to acquire STIs than women in communities with low rates of infection who engage in higher-risk sex.
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This suggests that the community within which you live and choose your partners has a major impact on how much risk you face.
Why might communities that are hard-hit economically, many of which are communities of color, have higher STI rates?
⢠Fewer hospitals and treatment centers and lower-performing and less funded schools mean less access to STI education, prevention, and treatment.
⢠Less money available for safer-sex supplies such as condoms.
⢠High incarceration rates. Owing to race, class, and educational bias, the U.S. criminal justice system imprisons a disproportionate number of people of color; more than 60 percent of the prison population is composed of racial and ethnic minorities, most of whom are from inner cities.
Some public-health experts have noted two troubling trends with so many African-American and Latino men behind bars:
One is the shift in the patterns of marriage and courtship that result when so many men are removed from a community. The other is an increase in the number of “multiple concurrent sexual partnerships,” in which individuals are
engaged in sexual relationships with more than one person at a time. In many communities, when one sexual partner is imprisoned, the person left behind chooses another partner. When widespread, this behavior creates an efficient, effective pattern for introducing and maintaining an STD through a network of sexual relationships.
Concurrent sexual partnerships, our research indicates, are a more effective engine for transmitting STDs than sequential partnerships. In the latter case, an infected individual is more likely to be diagnosed before a new partner is infected. In the former, an individual infected by one partner can immediately pass the infection on to another, potentially spreading it quickly through the network. As people move in and out of relationships and in and out of communities, such infections become almost impossible to treat efficiently. Movement in and out of prison aggravates these trends.
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Bradley Stoner, chair of the board of directors of the American Social Health Association, says the numbers are an important reminder that STIs are a critical public-health threat. The data on disparities, he says, “show that minority populations continue to bear a disproportionate share of the STD burden. It is time to focus more aggressively on STD prevention and control efforts, and turn our attention towards destigmatizing STD testing and treatment.”
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Increasing accessibility of STI services is crucial, as is involving the communities themselves in the design and delivery of the services. At the same time, we need to find ways to address the complex economic and racial injustices that contribute to these disparities. One of many groups working toward these goals is SisterLove (sisterlove.org), an Atlanta-based sexual health and reproductive justice organization with a focus on HIV/AIDS.
Cultural, biological, and economic factors may combine to increase women's risk of STI transmission. Despite the conventional wisdom that female sex workers are more likely to transmit HIV or another STI to male clients, it is actually more likelyâbecause of women's biological vulnerabilitiesâto be the other way around. Many male clients resist condom use or offer to pay more for unprotected sex. Some sex workers build on experience, by, for example, inserting a female condom before accepting a client or swiftly slipping on a condom as part of sex play. Indeed, in some communities, sex workers also work as effective safer-sex educators and have helped train other safer-sex educators.
Women's prisons offer another example of the interplay of biological and social factors. When women arrive in prison with an untreated STI, unhealthy living conditions and insufficient medical care can lead to less attentive treatment, more health complications and suffering, and a higher death rate from HIV/AIDS. Some prisoner-initiated groupsâincluding groups in Lexington, KY, Marianna, FL, and Dublin, CA, and in the Washington, DC, Detention Facility and New York's Bedford Hills prisonâhave worked to bring AIDS support, education, and awareness to prisons. The groundbreaking work of the AIDS Counseling and Education group
(ACE) at Bedford Hills has been documented in the book
Breaking the Walls of Silence: AIDS and Women in a New York State Maximum-Security Prison
.
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Prison officials have often opposed or disbanded these peer education groups, despite or perhaps because of their success at educating and organizing prisoners, but the ACE group was still going as of late 2010.
NEEDLE DRUG USE
All recreational drugs can impair judgment, and this may make it less likely that someone will practice safer sex. IV drug users also need to consider how to inject safely, as shared needles may be contaminated from a prior user with HIV or other blood-borne infections. A recent CDC study in California noted that in the preceding twelve months, 32 percent of injection drug users had shared works or needles, and 63 percent had had unprotected sex.
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Needle exchange programs have been successful in helping women reduce the risk of HIV transmission.
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In 2007, 16 percent of new HIV cases among U.S. women were due to injection drug use, down from 22 percent in 2002. Although most women with HIV become infected through unprotected intercourse with an infected man, the partner's drug use can be the source of the HIV infection that he passes on.
Injection drug use is particularly common in hard-hit socioeconomic areas where access to quality care and to treatment for addiction is inadequate. Inaccessibility of care can fall especially hard on women, who are more likely to have daily responsibility for children and may thus face extra obstacles to making use of any treatment or rehab options that are available.
Improving women's health experiences with STIs will depend on fundamental social changes that address poverty, racism, and sexism. It is important to make public officials understand that when particular communities are hard-hit by STIs, such factors are at workânot an inherent tendency to sexual infection on the part of any social group.
As the Department of Health and Human Services notes, a key to improving STI prevention and treatment efforts in communities hit hard by racism and economic distress is to involve community members “at all stages in the process of devising and implementing prevention and control strategies.”
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(For tips on creating culturally appropriate sex education programs, see “Empowering Our
Schools and Communities.”
)
