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Excerpts from Sacrificing Our Selves for Love

Chapter 10: The Costs of Physical Love

Continued

It is clear that high-risk activities are even riskier for some of us. The younger we are when we first have intercourse, the higher is our risk of developing PID, cervical cancer, and HIV disease. Age-related cell changes in the genital tract account for some of a young girl's increased risk. Our reproductive systems are not fully mature until several years after we enter puberty. Our cervical mucus may not have built up its full array of protective proteins. Also, some vulnerable cervical cells are more exposed inside the vagina in the early years after puberty, and are more vulnerable to damage from bacteria, especially chlamydia, and to viruses such as HPV. The vaginal wall is also not fully mature, but the significance of this regarding sexually transmissible infections is not known.

Some researchers speculate that in our teenage years we may have difficulty negotiating with partners about the extent of sexual activity and about safer sex; have rapid changes of partners; have more partners infected by a sexually transmitted disease; and delay seeking medical care, compared with older women.67 Sexually experienced teenagers are three times more likely to have PID than are sexually experienced women in their mid- to late 20s.68 Worldwide, the incidence of HIV in women peaks in the 15 to 25 year range, ten years before the peak for men, even though the normally acid environment in a premenopausal vagina may sometimes inactivate HIV.69 Conversely, loss of vaginal acidity after menopause results in decreased defenses against HIV, and transmission of HIV seems then to increase for each exposure.70 The vaginal wall also becomes thinner and is less lubricated, making vaginal imitation more likely and increasing susceptibility to HIV.

A few weeks ago, I had a blood test that showed an abnormally low white and red blood cell count. My doctor was concerned, and I said. 'Have you tested for AIDS?" She said: "No. You can't test for AIDS without the patient's permission. We're not looking for AIDS." I guess she just assumed that since I'm white, middle class, and in my fifties, I'm not infected.

I was living with my boyfriend for a year and a half and broke up six months ago. I didn't have sex with many boyfriends -- only three -- and Fred-- he only slept with two women. He seemed like such a sweet guy when I met him. So I figured we were safe and didn't have to use condoms. After I tested positive, I found out that Fred's first girlfriend used drugs for a time.

How Safe Is Your "One and Only"?

The government and some medical societies have advised us that if we take a few precautions we can reduce our risk of sexually transmissible diseases. These precautions are: to reduce the number of sex partners we have and to discuss past sexual and drug use history with our potential sexual partners. Unfortunately, these strategies give us unwarranted reassurance without real protection.

Advising people to have fewer sex partners or to save sex for a monogamous marriage is, in fact, rational from a statistical point of view -- the fewer contacts between people, the slower sexually transmissible diseases spread among the population. Knowing your statistical risk, however, does not tell you if you are going to be the one to get and spread an infection. A woman or man may have only two sexual partners, yet contract a sexually transmitted disease from the first partner and pass it on to the second partner. Restricting the number of one's partners seems to make sense because it is reinforced by social taboos against multiple sexual partners, especially for women. While playing Russian roulette with one bullet in the gun is certainly less risky than with three bullets, if you get the one bullet you are still dead.

Because of the supposed safety of monogamy, if you are currently monogamous you may have a false sense of being invulnerable to a sexually transmitted infection. However, a woman is safe in a mutually monogamous relationship only if both she and her partner start the relationship uninfected -- which is not always possible to tell. Both she and her partner must remain completely monogamous and continue to avoid exposure to nonsexual sources of infection such as unscreened blood or shared needles.

However, the reality of our sex lives is often not so simple. Studies of heterosexual couples in the United States show that relatively few people in this country have one lifetime partner that they make love with only after marriage. About half of marriages end in divorce, and many people remarry. Within marriage, a 1990 Kinsey survey found that 29 percent of wives and 37 percent of husbands have affairs.71 Premarital sex is increasingly acceptable. In the United States in the late 1980s, 17 percent of married people said that they had lived with someone prior to their first marriages,72 and this percentage is likely to have increased. A quarter of Americans over the age of 19 have never married and those who marry are marrying later,73 yet 97 percent of adults are sexually active at some time.74 Half of all pregnancies in the United States are unplanned, indicating that many people do not take adequate birth control precautions.75 Many more probably do not think about preventing infection when they have sex.

Despite popular belief, monogamy on our part in a long-term relationship does not keep us safe. A woman's risk of getting a sexually transmissible disease rises with her partner's exposure to such diseases as well as with her own. Studies from countries where heterosexual transmission of HIV is already common illustrate how, worldwide, many women who are infected have had sex with only one partner. In one Rhode Island study, 70 percent of the women who were infected with HIV were monogamous. The average number of lifetime partners of these infected women was three, the same as for those not infected.76 In the United Kingdom, 80 percent of women with AIDS were infected by long-term partners.77 As many as 60 to 80 percent of all women in Africa infected with HIV have had only one sexual partner.78 In the United States, around a tenth of women considered "low risk" (defined as those who are monogamous or have not had sex with a partner for at least two months), are infected with chlamydia.79 And a quarter of adolescent girls infected with chlamydia who attended four clinics in Atlanta, Georgia, had had only one sexual partner.80

In reality, the more often a woman is exposed to microorganisms, even from one or two partners, the more likely she is to become infected. Rather than reduce the number of people we have sex with, we need to eliminate or at least reduce the number of times we have unprotected sex with a person who may be infected, whether it is with one person repeatedly or once each with one hundred people.

WHAT YOU DON'T KNOW CAN HURT YOU

I'm very worried about AIDS and I'm glad I know what to do: abstinence is 100 percent sure; otherwise, I should use condoms. But I use the pill because I know that if my boyfriend was lying to me about what he was doing I could just see it in his eyes. 

When I finally realized that this was something that affected my husband as well as me I started asking him: "Have you been with anyone else? Have you been with anyone else?" He kept denying it -- but I was pretty sure he was lying. In the end, he came through very well. He was a product of his upbringing, the male model of "cheat on your wife and don't tell her " He cut through that, and he was able to say: "God, that's what I did; that's not okay. What a terrible thing has happened to us."

-Woman who developed PID

Asking our partners about past sexual and drug use history is a first step in expressing our concern about safety. And when we ask such questions, we want to believe that our partners will not lie to us; however, many of us suspect that our sexual partners are sometimes less than truthful. Statistics reveal that our suspicions are well-founded and that, indeed, we cannot rely on a partner's honesty. For example, in one survey, 20 percent of the men admitted that they would lie about their HIV status, and many said they would deliberately underreport the number of previous partners. About a third of the men and a tenth of the women admitted that they had already lied in order to have sex. Almost a quarter of the women and a third of the men had been sexually involved with more than one person at a time, and more than half did not tell their primary partners.81

Expecting honesty presupposes an equal relationship between two partners for whom honesty is of paramount importance. If a person fears that a partner will react angrily, be extremely hurt, or abandon the relationship, truth-telling is unlikely.

Even when partners are completely honest, they might not know that they are infected because early signs of infection are often not present. In addition, many women erroneously believe that they can tell if their partners are infected by watching for physical dirtiness, pimples, or greasy hair. This can be a fatal assumption. Even clinical tests for a sexually transmissible disease may not be accurate because a time lag may exist between infection and a "positive" test.

Gonorrhea, for example, usually causes obvious symptoms in a man but you may not be able to inspect his penis to observe an infectious discharge. Moreover, a man can be infected for two weeks or more without having any symptoms. Some men never develop noticeable symptoms and unwittingly infect one or more partners. Men are also often unaware that they are infected with chlamydia and may therefore unknowingly spread the disease. In the United States, chlamydia incidence among men appears to have risen dramatically since the 1980s, afflicting an estimated 800,000 men annually, twice as many as suffer from gonococcal infection.82 Up to 25 percent of infected men have no signs or symptoms of infection.83 Both gonorrhea and chlamydia can also infect women for long periods of time, even years, without causing symptoms. During this time the women can unknowingly pass these bacteria to sexual partners. As many as 70 percent of women infected with chlamydia may be without symptoms or have symptoms so mild that they do not suspect a serious problem. At times the immune system appears to be successful in suppressing chlamydia and even in curing it. Therefore, a woman may infect her partner or partners without ever knowing that she has had the disease.

Similarly, many of those who are infected with HPV infect others without realizing it. We cannot possibly tell if a male partner is infected with a high-risk HPV, and he himself is unlikely to be aware of the fact. Even many physicians do not realize that the types of HPV infections that are most likely to lead to cervical cancer are often not visible to the naked eye. A woman can be infected for years with no symptoms before she becomes aware, usually through a Pap test, that she is infected.

Symptoms of HIV infection often do not appear for years, even though a person is infectious during that time. While blood tests can identify the presence of antibodies to the virus, most people do not get tested until after they become ill. And commonly used HIV tests actually test for antibodies to HIV rather than for the virus itself. Because it takes time for the body to make enough of these antibodies to be found in a test, for a period of several weeks to months a person can be infected and still have a negative test.

In many cases we do not have the information we need to be able to protect ourselves. Young women are particularly at risk partly because our own, our teachers', and our physicians' educations have not caught up with the rapid changes in adolescents' sexual habits. This gap leaves us with the greater likelihood of being sexually experienced before we have learned how to protect our health, and without having the medical and social services we need. Currently, 7.5 percent of girls and 19 percent of boys are sexually active by age 14.84 And 80 percent of urban teens have had sexual intercourse by the time they are 19.85 In a nationwide survey almost two-thirds of the male and just over half of the female students had had sexual intercourse by age 17.86

Sometimes we are unaware that certain activities are risky. For example, anal intercourse is fairly common among heterosexuals in the United States. As many as 61 percent of women who responded to a variety of surveys report having anal intercourse, 87 but few heterosexuals talk about it. We may not think of anal intercourse as "real sex" or may use it as a way to avoid conception, not realizing that we need to think about protection against diseases. Because most of the health information about anal sex is directed toward gay men, women may be unaware of the relative ease of disease trans- mission through anal intercourse.

The fact that both men and women can have gonorrhea, chlamydia, HPV, or HIV without noticing it, at least for a while, contributes to the spread of these infections. However, even symptoms do not guarantee that people will cease the sexual activities that spread the infections or that they will seek treatment. Some of us and our partners do not recognize mild symptoms as signs of disease; do not want to believe that we could have a sexually transmitted disease; or mistake our symptoms for problems unrelated to sex. In addition, some of us continue to have unprotected sex even when we know that we have an infection. One study of people who attended a clinic specializing in sexually transmitted diseases showed that 46 percent of women and 38 percent of men who came for an evaluation reported that they had had unprotected intercourse after their symptoms occurred.88 In addition, many of us may have difficulty asserting ourselves in sexual situations even when we know how to protect ourselves and know that we should be doing so.

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