Thursday, January 31, 2013

Between Herpes and a Hard Place

 From the CDC:
Genital Herpes—Initial Visits to Physicians’ Offices, United States, 1966–2010

Note: Valtrex was approved by the FDA in 2003.
The first time one of my friends told me they had herpes I was a total asshole about it. I had been writing for Go Ask Alice!, the Q & A website run by Columbia University, and I'd been assigned a question about when a person should tell potential partners they had herpes. I wrote something like "OMG YOU HAVE TO TELL THEM IMMEDIATELY!!!" because, as someone who didn't have herpes and, at the time, didn't know that I knew anyone who did, the prospect of having a partner with herpes totally freaked me out.

My friend, M, who is my sex-ed-bestie and also has herpes, took me to task. The assumption that people engaging in hookups or sex with partners that they don't ask about STI status are safe from herpes is not, in fact, a safe assumption to make, she told me, and her obligation as someone with herpes was equal to a sexually active person's obligation to ask their partners if they had been tested or if they had any STIs. That kinda blew my mind. Case law in the California tort system bears this out.

One of the two main reasons I see people for individual consultations is herpes diagnosis (the other: erectile dysfunction). Last fall I saw a student who had gotten diagnosed with genital herpes after hooking up with a guy in a prestigious, all-male social organization on campus. She told him about the outbreak, and he never talked to her again. She came to me when she was already having sex with but only "almost dating" someone new, and she started having symptoms again and wanted to know if she should tell him.

I was shocked that this girl had already started fucking this guy and consciously chosen not to tell him about the herp--exactly what the bro she'd had sex with had done to her. But why didn't the guy she was having sex with ask her if she had been tested? She, like many of the students I see, hadn't been using condoms because she was on the pill. Head, meet desk.

Consistent use of condoms, though not perfect, is the best way we have to reduce the risk of skin-to-skin STIs like herpes and HPV. But surveys of college student sexual behavior show that only 35% of students actually use condoms every time they have sex. Fully 30% of college students who report having had vaginal sex say they used "withdrawal" as a contraceptive the last time they had sex. Only .7% of survey respondents say they have were diagnosed or treated for herpes in the past year,* but at my clinic herpes diagnosis is as common as chlamydia, which is the most common STI tracked by the CDC.

Research tells us that the # 1 reason young people use condoms is to prevent pregnancy and usually only with new partners, and once another birth control method is being used people are significantly less likely to continue using condoms. But condom use has never been that high and, among certain groups, it is on the decline.

In its 2012 National Health Statistics Report on contraceptive use in the US, the CDC found that between 2006 and 2010, 30% of people with private insurance used the pill while only 17% of those with public insurance (i.e., Medicaid) and 14% of those with no insurance used it. The pill is more effective at preventing pregnancy, sure, but it provides zero protection from STIs. Conversely, 19.6% of women with no insurance used condoms compared to 16.3% of those with private coverage.

Those rates changed significantly between 1995 and 2006. In 1995, 22% of women between 0 and 149% of the poverty level used the pill; 27.5% of women 400% or higher used it. In the 2006-2010 cohort, 39.2% of women at 400% or greater used the pill while only 19% of women at the lowest tier did. Condom use declined among women in the top tier from 23.5% in 1995 to 17.7% in 2006; use among women in the lowest tier stayed basically the same.

As pill use increases, condom use decreases, both in individual relationships and at the population level. Decreasing use of condoms and increasing sexual contact with more partners--including oral sex--increases the exposure young people have to STIs and people who use the pill only are setting themselves up for infection. 

In my own experience, young people tell me the conversations they have about STIs (if they have them at all) go something like this: "Do you have anything?" or "Have you been tested?" To which the only acceptable answers, regardless of the truth,  are "No" and "Yes." Birth control, similarly, is often discussed in the same way: "Are you on the pill?" and if the person says yes sex goes forward with no concern for condoms. If the person says no...well, 1/3 of young people are using withdrawal.

I guess, for most people, talking about STI testing and condoms is a boner-killer; but I know people who have herpes and have casual sex and make this work. Here is what I've learned:
  • You are not, as a person with herpes, obligated to disclose immediately upon meeting (or, say, in your OkCupid profile) that you have herpes. 
  • People who are out and about having sex with other people have an obligation--both legally and in terms of common fucking sense--to ASK about STIs rather than assume that a conversation not had by either partner means nobody is infected. This means three things:
    • People should ask about STI status. 
    • People should get tested so they know how to answer the STI status question.
    • If one or both partner hasn't been tested since their last partner, people should use condoms until both partners have been tested.
  • Finding out you have herpes is sort of like becoming a member of a secret society: you don't know who else is in the club until you're in. The absolute best thing you can do if you find out you have herpes is get connected with a local HELP group, peer-led groups of people with herpes that are anonymous and provide support with diagnosis.
Getting diagnosed with herpes sucks, but the infection is not fatal, doesn't cause problems with later fertility, and never progresses to anything worse: the shame totally outweighs the seriousness of the infection. But the stigma is huge and there is no 'ribbon' for herpes; there is no 'walk' for herpes; there are no celebrity concerts for herpes. So if someone you know and love tells you they have herpes, don't be an asshole--chances are really good you've been exposed, too.