In this interview, Ashley Winter, MD, discusses why urologists should play a role in the management of STDs and STIs, especially when it comes to destigmatizing them.
Sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) are conditions that are typically consulted with primary care doctors; however, stigmas associated with these conditions have left patients quiet. Therefore, when STDs and STIs are left untreated, urologic problems ensue.
In this interview, Ashley Winter, MD, discusses why urologists should play a role in the management of STDs and STIs, especially when it comes to destigmatizing them. More specifically, she explains the unmet need for screening and counseling for these patients. Winter is a urologist at Kaiser Permanente in Portland, Oregon.
I'd say another way to rephrase that is "misconceptions" around STDs or STIs. [One] common misconception [is] that the only people who get sexually transmitted infections are young people, like teenagers or people in their 20s. Certainly, if you are sexually active or even not currently sexually active but have ever been sexually active, you can be diagnosed for the first time with an STI. I think that's particularly relevant because in general, urology populations tend to be older and people who are older tend to not think that they can get them. So, I think that's a really important misconception to be aware of. Now, while they're more common in people of younger ages, they're certainly not isolated to them. It's not like after you hit 35, you're immune to sexually transmitted infections. There are certain specific patient populations you think of, like assisted living facilities, where you maybe have a large congregate living setting, and you have people being sexually active with each other who sometimes are not using protection because they're beyond the childbearing years. They may think that they don't need it as much and they can still transmit other sexually transmitted infections, such as chlamydia, gonorrhea, syphilis, [or] herpes. So, that's a big misconception.
I think [another] misconception that's really important is that monogamous people don't get STIs. [An] example is that herpes is [an] extremely common sexually transmitted infection, and there's some data that up to 87% or so of people with herpes are asymptomatic carriers, meaning that if you tested their blood, they'd be seropositive. [You'd] say, "Oh, this person has herpes simplex virus, but they never had an outbreak. They never had herpes lesions." That person, let's say, could be in a monogamous relationship, and they could transmit it to their partner. Asymptomatic transmission is a possibility. And there is even a specific New England Journal of Medicine article looking at this, showing that there were people who were in long-term, committed monogamous relationships, where one of the partners, let's say, showed up positive for the first time with herpes that they that they got from an asymptomatic partner, where there had not been any other sexual activity outside of the relationship. Let's say, one of the partners goes to the doctor, gets diagnosed for the first time with herpes, [and] they're a year into their relationship. They go home, tell their partner, "Hey, I have herpes," and then get accused of cheating or something, right? No, it's actually possible that you were in a committed monogamous relationship without anybody stepping out on the side, and that there was a first-time diagnosis of a sexually transmitted infection. Also, some sexually transmitted infections have a higher rate of asymptomatic carrier status in males than in females or vice versa. So, those sorts of things are possible. I'd say that's another misconception.
And then I just think from a stigma standpoint, there's been such a focus on sex ed in school systems that doesn't focus on understanding these diseases, but [rather] focuses on things like abstinence only. Unfortunately, saying, "If you don't ever have sex, you won't get an STI," is not effective because human nature is such that humans are sexual beings. Teaching abstinence only doesn't ever prevent people from engaging in sexual activity, so you really need to educate, and when you don't educate and you just say, "Don't have sex," then sexually transmitted infections become highly stigmatized. [It's] this idea of "you failed" or "you're dirty," and that you don't take your health seriously. Those are the top 3 that come to mind. One, that it's only for young people, 2, that you have to have multiple sexual partners to get an STI, and 3, the stigma associated with our educational formats that stress not having sex over understanding how these conditions are treated.
Because there's so much stigma, patients don't want to bring it up [to physicians]. Sometimes they do, but oftentimes they don't. People will just be hesitant to bring it up, or they'll not want to be tested for it. I've had somebody come in the office, and they [had] burning with urination and they had blood in their urine. They didn't have any sign of a bacterial infection and ended up doing a cystoscopy. Their cystoscopy showed what looked like herpes lesions inside of their urethra, which is possible. And I said, "I think you have herpes." And they say, "I couldn't have that," essentially, because they feel like I'm shaming them. I wasn't trying to shame them. I don't impute any moral value on having an STI diagnosis. I was bringing it up because I wanted to provide effective treatment. So, when somebody says in their mind, "Having this diagnosis is negative, and my doctor talking to me about it is an accusation," then it makes resistance to treatment because it's admitting something bad about yourself, when it shouldn't be that. If your doctor said, "Hey, you have high blood pressure," you wouldn't say, "I am a good person, I couldn't have high blood pressure." So, we need to just approach STIs as the medical conditions they are because until we do, and until we take those stigmas away, people will truly have resistance to discussing it, hesitance to discussing it, and resistance to diagnosis and intervention.
The first, of course, is just treatment. If somebody has an STI—things like chlamydia, gonorrhea, [or] syphilis—having a low threshold to talk to your doctor if you're concerned that you have an STI and being screened and treated for it within a rapid time frame is going to improve your quality of life. Chronically untreated chlamydia [or] gonorrhea can lead to fertility problems [or] chronic pain. Syphilis, more directly, if untreated and progresses to some of these later stages, can have permanent health effects. Those are all things [for which] lowering our stigma and having a lower threshold to diagnose and treat are going to be helpful. And then there are some really innovative things from the standpoint of viral suppression in terms of managing quality of life. [One of the] biggest ones that come to mind [is] herpes suppression. When you think of, [for example,] valacyclovir, commonly known as Valtrex, that can be given to somebody with frequent outbreaks, or even potentially somebody who's asymptomatic who has a partner that's not positive for herpes to reduce transmission. That can improve quality of life. Yes, herpes cannot be cured, but there are options, if you have frequent outbreaks, to reduce the frequency of the outbreaks, and there are options, if you're in a relationship or even having any sexual partners, to improve the safety of your partners by being on that viral suppression.
Obviously [another] huge one is in the HIV space. HIV is a sexually transmitted infection, and when it initially came on the scene, it was a deadly disease. With modern anti-retrovirals, it's really a diagnosis and not a death sentence. Most individuals with HIV live full lives with normal life expectancies. And so, anti-retrovirals [are very efficacious]—A, from the really obvious standpoint of maintaining life and health, [and] B, from the standpoint of making somebody have undetectable viral loads and allowing them to engage safely in sexual activity. Those medications [are] also being used in pre-exposure prophylaxis [PReP], which is where we have high-risk individuals taking it who aren't even HIV positive. We've come to a point in time where you could have, let's say, somebody who's in a relationship with someone who's HIV positive, and they are not HIV positive. The non-HIV positive person is taking PrEP, and the HIV positive person is on their anti-retrovirals and has an undetectable viral load, and they are safely having intercourse without protection and can be confident that they are not going to transmit the disease, which is really a radical paradigm shift from the way we conceived of HIV 30 years ago. So, that's really incredible.
Now, the ability for these things to be treated, of course, does not diminish the importance of having safe sex, or using condoms. And I think that there is some kind of safety net in our minds—because of the treatability of these conditions—that has potentially reduced the use of things like condoms, and what we are seeing as increasing rates of, particularly, chlamydia and gonorrhea throughout the last several years. With gonorrhea, [there are] some multi-drug-resistant forms of gonorrhea that are very hard to treat, and these are really on the rise. I think as all our public health attention is focused on COVID, we've turned away from the struggling rates of chlamydia, gonorrhea, and even syphilis in this country. [It] definitely is important to incorporate use of condoms and other types of barrier protection if you're having multiple partners.
If a patient comes in and wants to ask for that screening, just be supportive and offer it. [Don't] be judgmental. I hear horror stories of a doctor saying, "You're really getting it on," or making comments that are just judgmental. Don't do that. Do what you're there to do, which is provide care.
I think another thing that can be done—I know there's an overuse of questionnaires—[but] including questions [such as], "Would you like to be screened for STDs? Are you concerned about any sexually transmitted infections?" on your intake questionnaire can be helpful. Sometimes the patient is afraid to bring it up in conversation, but when they're checking those boxes, they feel more comfortable, and then it gives the clinician the space to initiate that conversation during the encounter. So, that can be helpful. I think just remembering, again, that it [can be] any age of your patients [is important]. In 6 years of urology residency, we talked about sexually transmitted infections very rarely. I think the concept amongst urologists is it's a primary care thing, but undiagnosed STIs can have a lot of overlap with conditions we treat. So, if you're talking about chronic pain, dysuria, hematuria, various sexual dysfunction, [or] testicular pain, we have to be keeping these things in our differential diagnosis and not assuming that somebody in the primary care environment has already gone into that, especially as our patients age and they may be seeing a urologist more frequently than maybe even their primary care. If I have a bladder cancer patient, I might be seeing them 4 times a year, whereas they might have seen their primary care once. So, be open and available to that aspect.
Sex is wonderful, and people of all ages should enjoy it. Don't feel hesitant to talk to your doctor about it, and if they are not making you feel comfortable, find somebody who does because sex-positive providers are something that all people deserve to have.