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Patients fail to do their
part in prevention for a number of reasons. Some get
tested only for HIV because it has the biggest public
profile. Some discover they have rashes or discharges
but then just shrug them off. Still others make the
mistake of assuming they can't be at risk. "I had never
been sexually active before my ex-husband, so STDs were
the furthest thing from my mind," says Elaine Sweet,
a 37-year-old policy analyst from Phoenix who has a
strain of HPV that causes cervical cancer. "It never
occurred to me that his past would come back to haunt
And then there's the stigma
and shame of STDs. "We don't have famous people coming
forward and saying, 'Can I be the poster child for herpes?'"
says Gilbert. "STDs are very hidden, secret, and mysterious;
and that's helping these germs replicate like crazy."
Afraid of discovering that they are infected-or of being
pegged as promiscuous-patients may be too timid to broach
the subject with their doctors. Doctors, in turn, may
be reluctant to step forward and make the first move.
One KFF survey found that they were even less likely
to broach the topic than their patients. "Some patients
get insulted if you ask about STDs," says Dr. Robert
Hagler, chair of the gynecological practice committee
for the American College of Obstetricians and Gynecologists.
"You run the risk of offending them, and this can make
discussing STDs difficult."
|As always, money complicates
the issue. Many insurance companies refuse to cover testing
that they don't deem "medically necessary." But if an
STD is asymptomatic, "necessary" becomes a slippery slope.
As Hagler points out, most HMOs set a ceiling fee for
routine gynecological exams. If the cost of STD screening
exceeds that limit, patients have to reach into their
own pockets to pay for each $20 to $60 test. Add to that
the fact that there are 44 million people in the U.S.
that have no health insurance at all.
According to a survey
by the Commonwealth Fund, women with no insurance and
those who rely on Medicaid are more likely to discuss
STDs with their doctors than women who see private physicians.
But patients who rely on neighborhood clinics aren't
necessarily getting better care. "At some public clinics
in some states, the government won't pay for adequate
screening," says Dr. Michael Burnhill, vice president
for medical affairs at Planned Parenthood Federation
of America. "These clinics use tests that have been
around 20 years and aren't the most accurate or sensitive
ones on the market." According to the Alan Guttmacher
Institute, a reproductive rights advocacy group, the
public sector spends $1 to prevent STDs for every $43
spent on treatment. Yet another hurdle is the lack of
set protocols. Each HMO has its own guidelines for STD
screening. And that's just one set of marching orders.
The American College of Obstetricians and Gynecologists,
American Medical Association, Centers for Disease Control
and Prevention, National Committee for Quality Assurance,
and ASHA all have separate recommendations. None of
these wield the force of law and no two are exactly
set protocols, doctors are left to their own devices
to assess which patients are at risk. If they're in
the Southeast, they might test for syphilis, which is
more prevalent in that part of the country. If they're
examining a patient who's under 25, they may test her
for chlamydia and gonorrhea, which are more common in
younger women. Beyond that, it's a matter of guesswork.
"Often doctors have little more than appearance to base
their screening decisions on," says Gilbert. "But it's
impossible to look at someone and know if they're really
at risk. STDs don't discriminate. You can't tell someone's
STD status based on age, race, or socioeconomic factors."
Until modern medicine
makes sense of the muddle, women must take charge of
their own STD screening. Our very lives depend on it.
We're more likely than men to suffer long-term health
consequences: HPV can lead to cervical cancer; chlamydia
can cause infertility and ectopic pregnancy; and, left
untreated, HIV can be fatal. Women also face the added
threat of transmitting infections to their unborn children.
The tragic consequences can include premature birth,
low birth weight, conjunctivitis, blindness, pneumonia,
neurological problems, and congenital abnormalities.
To avoid these disasters,
women need to step forward and get routine annual STD
screening. Health advocates urge every woman to
do the following:
- Get tested if you've
had multiple partners, sex without a condom, or a
partner who may have put you at risk.
- Get tested before having
sex with someone new instead of checking for infection
after the fact.
- Find out whether your
health plan covers STD screening and head to a public
clinic if it doesn't.
- Jot down questions before
your appointment and review them with your doctor
when you're most comfortable (sitting in an office
chair instead of strapped in metal stirrups). Which
STDs will you be screened for? (The answer should
be the eight most common ones, which are, in order
of incidence, HPV, trichomoniasis, chlamydia, herpes,
gonorrhea, hepatitis B, syphilis, and HIV.) How up-to-date
are your doctor's tests? (The answer should be no
more than five years old.) Is your doctor aware of
new advances in screening? Will any of these be available
to you? - Discuss your frequency of condom or dental
dam use, number of past and present partners, and
whether you engage in risky practices like anal sex.
'Fess up to all the nitty-gritty, and never succumb
- Head back for annual
testing as long as you remain sexually active. Take
charge of scheduling your appointments: if you don't,
your doctor may not.
Find that your doctor isn't
cooperative? Find that she or he shrugs off STDs? Then,
like Eileen Duffy, you may want to consider switching
health care providers. "We live in an age where a woman
can't assume she's not at risk," says Amy Allina, program
director for the National Women's Health Network. "There
are life-threatening STDs out there, and protecting
your life should be something that your health care
provider is concerned about."
M. Ginty is a freelance writer based in New York City.