|Eileen Duffy* was baffled by the bumps. Suddenly appearing around her vagina, they looked innocent and harmless enough: small, round, white, and soft to the touch. But they tingled and itched, so shortly after finding them, she shut the bedroom door of her off-campus apartment and called home hoping for help. When her mother couldn't peg the cause of the problem, Duffy dashed to the health clinic at her East Coast college.
"After the doctor examined me, she said, 'My God! You have genital warts!' in the most offended voice possible," Duffy remembers. "She didn't offer any advice. She didn't offer any information. She responded with complete disgust. I was shocked as I sat in her office, and I cried when I went home. Being told you have an STD is bad enough. But my doctor offered me no compassion or help whatsoever."
At the time, Duffy was 20 years old and had had less than a handful of sexual partners. Now 31 and a graduate student at the University of California, Berkeley, she has learned to live with the threat of recurring genital warts and with the incurable but treatable human papillomavirus (HPV) that causes them. But, like the millions of women in this country who have sexually transmitted infections-and the millions more who are at risk for them--she's still waiting for adequate and comprehensive care when it comes to her sexual health.
According to the Kaiser Family Foundation (KFF), a nonprofit organization that tracks health care policy, 15.3 million STDs are contracted annually in this country. The U.S. has the highest infection rates of any industrialized nation. Every year, STDs cost more than $8.4 billion in treatment. Experts say we could slash this expense (and eliminate untold pain and suffering) if we pledged to take one simple step: provide effective screening and treatment during medical exams.
"Many women don't know what they're getting when they go in for a gynecological exam," says Dr. Lisa Gilbert, director of the women's health program for the American Social Health Association (ASHA), a nonprofit organization devoted to STD education. "They don't realize that a Pap smear detects changes in cervical cells without testing for any specific diseases. They don't realize that practically every STD requires a separate diagnostic. Because they don't understand the difference between a Pap smear, a pelvic check, and an STD test, they walk away thinking they've had all their STD tests when, in reality, they've had none."
Tests for common STDs include cervical swabs for chlamydia and trichomoniasis, follow-up testing of abnormal Paps for HPV, and blood tests for herpes, HIV, and hepatitis B. Patients don't realize they're not getting these tests, and doctors aren't coming out and telling them. Recent surveys show that this silence is widespread. KFF found that 40 percent of women aren't asked about their sexual histories on pre-exam questionnaires. And according to the Commonwealth Fund, 84 percent of women and 72 percent of teenage girls hadn't discussed STDs with their doctors in the year preceding the survey.
Why do so many patients fall through the cracks? Experts point to a lack of public awareness. People fail to grasp the fact that STDs are a real threat: transmitted through oral sex as well as intercourse, lurking in the systems of the mutually monogamous, and often asymptomatic or unnoticeable (which is the case with chlamydia, herpes, and HIV). People don't learn how to best protect themselves: condoms and dental dams are the most effective methods, followed by diaphragms, cervical caps, or spermicides. According to a KFF study, 74 percent of men and 69 percent of women who are of reproductive age seriously underestimate the prevalence of STDs, guessing that one in ten Americans will become infected during his or her life. Although one in ten seems scary, the truth is even more alarming: the real number is one in four. Says Tina Hoff, director of public health information for KFF, "People seem to believe that it just can't happen to them. There is such denial that it's really astounding."
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 me."
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 alike.
Without 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 to embarrassment.
- 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."
Molly M. Ginty is a freelance writer based in New York City.