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Sexually Transmitted Disease:
An Occupational Hazard of Being Human
by Thomas W. Shinder, M.D.
Every profession has its attendant "occupational hazards." Physicians worry about malpractice liability, police officers are potential victims of an assailant's bullet, writers risk carpal tunnel syndrome, and electricians face the threat of shock injuries. Prostitution has its own set of occupational hazards in the forms of violence, drug-related dangers, and sexually transmitted diseases (STDs).
Reliable statistics are not available for the incidence and prevalence of sexually transmitted diseases among working prostitutes in the United States because of the illegal nature of this activity. COYOTE, an international union for professional prostitutes, estimates that among "street walkers" 80% have had at least one STD within the last year.
Of course, one does not have to practice the "oldest profession" (or even, in some cases, be sexually active) to become intimately acquainted with these infectious diseases. The common pathway to the acquisition of STDs is contact, either genital or orogenital (oral-genital).
There is a large cadre of diseases which fall under the moniker of "sexually transmitted," but I will focus here on those that are the most common and/or most severe. Whether contracted at work or at play, the symptoms and treatments are the same.
Syphilis has been part of human culture for thousands of years. Its introduction into the human population is believed to be from sheep that were the original carriers of the disease. The study of syphilis makes up a large part of the medical research during the modern age of medicine, with entire courses of study and journals dedicated to the study of "Syphlology." The disease earned a reputation as the "great imitator" because of the number of ways in which it could present itself in later stages, affecting the skin, brain, eyes, heart, and joints. The history of syphilis parallels the history of mankind, and especially that of Western Europe. Many of the great leaders of western civilization were known to have the disease, and frequently the dementia which accompanies its progression.
Syphilis is an insidious disease because of its neurological consequences when not treated early. After a person is exposed to the spirochete (the bacterium which causes the disease), he or she is typically without obvious symptoms for about three weeks. After this "latent" period, a sore (the "chancre") will appear on the man's penis. Women may demonstrate chancres on the external genital area, but typically they are inside the vagina and thus may go unnoticed.
Following the initial appearance of these sores comes swelling of the lymph nodes in the genital region and in the legs. If untreated, the lymph node swelling will spread to the entire body. At this point the spirochete is considered "generalized" (affecting the entire body). After this period,if still untreated, the spirochete seems to go into hiding. Decades later, the effects of "tertiary syphilis" (the third stage) appear. This involves inflammation of blood vessels (including the aorta) and invasion of the central nervous system, which causes memory loss, personality changes,confusion, and finally "insanity."
It's not uncommon for a neurologist to have to tell a woman whose husband died years before that she may have contracted syphilis from him after he came home from "the war" (usually World War I or II). This is often more embarrassing for the physician than for the patient. The elderly woman often recalls having a "female problem" soon after her husband's return, which subsequently "went away" on its own - only to manifest itself decades later.
Treatment for syphilis in early stages is relatively simple, a single injection of ceftriaxone (a penicillin-like antibiotic). For those who are allergic to penicillin, other medications are available. Prolonged treatment with intravenous antibiotics is required for late-stage syphilis.
Gonorrhea is often seen in concert with syphilis and treatment is similar. One of the factors which makes this disease problematic for women is the difficulty of early diagnosis. This is because it resembles other diseases affecting the female genital tract. The first symptoms include abnormal menstrual bleeding, vaginal discharge, and painful urination, all of which are seen with many other disorders. The most common misdiagnosis is cystitis, in which case oral "sulfa" antibiotics or urinary anesthetics are given, both of which are ineffective against gonorrhea.
Left untreated, the gonococcus (the bacterium which is responsible for gonorrhea) can spread throughout the body. It can cause inflammation of the liver, infectious arthritis (an arthritic syndrome from gonococcal infection of the joints), sterility, and in rare cases, meningitis.
As with syphilis, gonorrhea is easily treated in the early stages with an injection of ceftriaxone. In the later stages, when other organ systems become involved, prolonged intravenous therapy with antibiotics is necessary.
Herpes Simplex (both types 1 and 2) causes painful, itchy sores in the genital region and is accompanied by fever, malaise, and muscle pains throughout the body. There is frequently pain on urination and defecation, which is sometimes exquisite. Most people (prevalence is estimated as over 90% of the U.S. population by the age of 50) have already been exposed to HSV-1 (herpes simplex virus type 1) during childhood, as this is the same virus which is responsible for the common "cold sore." The first genital outbreak for those already infected may be less severe than those not infected. Herpes is a recurrent disease, with flares and remissions. The frequency of episodes varies from person to person, and can be as rare as once a year, or as often as once a month.
While syphilis and gonorrhea are "curable" diseases, Herpes can only be "managed" at this time; there is no cure. But there is good news: in the last several years, an increasing understanding of how DNA viruses behave has allowed more sophisticated and effective treatment of this disease.
Acyclovir was the first treatment found to be successful in reducing the frequency of attacks, and since then, famciclovir and valaciclovir have demonstrated themselves to be potentially more effective and less toxic. Both of the medications are taken daily by mouth to reduce the likelihood of recurrences.
With the onslaught of AIDS and resultant horror stories, the lay public and popular press have considered Herpes to be more of a "nuisance" disease than one of severe medical consequences. This isn't necessarily the case.
One woman told me that she had contracted genital herpes after oral sex with a new partner. About a week later, she told me that her new boyfriend had been admitted to hospital for herpes encephalitis (infection of the brain by the herpes simplex virus). The results were devastating, with his infection leaving him unable to form new memories and with a temporal lobe seizure disorder, drastically altering his life forever.
The most feared and probably best known of all sexually transmitted diseases is AIDS (Acquired Immune Deficiency Syndrome). AIDS is both incurable and lethal, although new treatment strategies are improving the span and quality of life of those afflicted with the disease. It is difficult to describe the "classic" presentation of this disease, because it can present itself in so many different ways.
HIV (human immunodeficiency virus) attacks white blood cells responsible for essential elements in the maintenance and coordinated functioning of the immune system. Any organ system can be affected by HIV infection, with the marrow, brain, lungs, and kidneys perhaps most severely involved. While opportunistic infections (infections taking advantage of the dysfunctional immune system) are responsible for the majority of deaths, the virus itself infects the brain and its supporting structures. This causes the brain cells to release toxic substances and creates symptoms of memory loss, personality change, and confusion.
The most common early symptoms include easy fatigability, muscle aches and pains, bone pain, chronic unremitting headache, and difficulties in concentration and memory. While these symptoms are non-specific in nature, a "red flag" should go up if the person has had sexual contact with someone from a high-risk group (IV drug users, homosexual or bisexual males) or unprotected sex (without condoms) with casual or multiple partners.
A cure for this disease is something we may look forward to in the future, and treatment regimens continue to improve. It is far outside the scope of this article to discuss the variety of treatments available. They typically consist of multiple oral medications that interfere with virus replication (or reproduction), reducing the overall number of virus particles in the body. This appears to allow the immune system to function at acceptable levels and ward off the secondary infections which are usually the cause of death.
There are many other diseases which fit into the category of STDs, such as Lymphogranuloma Venerum, Mulluscom Contagiosum, Chalymdia, Chancroid, Hepatitis B and C, Giardia, and Cytomegalovirus. The best treatment is prevention. Not even abstinence can be considered completely effective, since some STDs can be spread by contact other than intercourse, but at this time, use of the male condom offers the best probability of reducing the chance of contracting one of these sexually transmitted diseases.
Thomas W. Shinder, M.D. is a neurologist and a computer enthusiast, who finds the "mind of the machine" almost as fascinating as the human brain.
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