Sex and sexually transmitted infections (STIs) are surrounded by a centuries-long history of stigma that to this day negatively impacts our reproductive and overall health, which is especially problematic due to the widespread nature of STIs.
More than 1 million STIs are acquired every day worldwide, with the majority being asymptomatic, said Erica Montes, M.D., board-certified OB-GYN and medical advisor for the Body Agency, a "femtech" platform based in Maryland.
"The incidence is definitely higher among those individuals that have barriers to health care such as language, lack of insurance, transportation, cultural differences," Montes explained.
Yet clinicians still hear the same myths when they treat someone with an STI. One of the more recent examples of misinformation is that taking HIV pre-exposure prophylaxis (PrEP) medication protects you from all STIs. People who believe this myth have then stopped using condoms—leading to an increase in sexually transmitted diseases (STDs) such as chlamydia, gonorrhea and syphilis.
The reported number of STD cases continues to climb year over year, according to the Centers for Disease Control and Prevention (CDC). In 2019, there were more than 2.5 million reported cases of chlamydia, gonorrhea and syphilis in the United States.
Misinformation remains rife, aided by an unwillingness to openly discuss STIs and testing. With costly consequences, why aren't we willing to talk honestly about sexual health?
A lack of understanding
Montes has a straightforward hypothesis: "This is because people don't want to hear or talk about it. Therefore, it reduces their knowledge of these infections."
Ona Croft, a registered nurse working in general practice in the United Kingdom, said she is often surprised by the lack of knowledge and understanding of STIs.
"There is more knowledge around some STIs and STDs—chlamydia and HIV—than others: gonorrhea, syphilis, hepatitis B. Again, I'm not sure why," Croft said. "I know there has been lots of money spent on advertising to educate young people on chlamydia, and HIV has been widely discussed in the media for many years."
Beyond large-scale campaigns, methods such as one-on-one outreach, especially targeted for key demographics, could make the difference in STI prevention and management.
"We need educators and health professionals to talk openly with their patients, especially teachers and pediatricians who are in a position to get the message to people when they're young," said Emily Rymland, a doctor of nursing practice and certified HIV specialist at Nurx, a healthcare company in San Francisco. "Creating youth-friendly, science-based social media could be helpful.”
The stigma surrounding STIs
In her line of work, Rymland sees too much shame and stigma around sex, which turns into STI stigma that only worsens the cycle.
"People are scared of being judged or that somebody will think less of them if they have an STI," Rymland explained. "The desire to be attractive to or loved by a partner prevents people from raising the topic of STIs and demanding testing and condoms."
"Sex is an intimate subject for many," Croft added. "Being infected with an STI is still more stigmatized than getting a cold or any other viral illness. I think there is much misunderstanding and a reluctance to ask questions."
Such silence perpetuates the proliferation of STIs, according to Rymland. "People always think it is others that will get infected and have a 'that can't happen to me' mindset," she said.
Croft said it's vital for people to have access to reliable, accessible sources of information that speak to them in their language. For example, information aimed at younger people likely won't resonate with older people.
5 common myths
To combat misinformation around STIs and STDs, we have to address the common myths that still persist:
Myth 1: STIs happen only to promiscuous people.
Anyone can catch an STI and not always through sex.
"STIs such as herpes can even be transmitted with kissing alone," Montes said. “So, because they are so common and so contagious, it's important to get the facts."
Myth 2: STIs are a problem only for gay people.
This is an ongoing misconception, but it's not accurate. STIs are a potential problem for everyone. They are spread through any kind of unprotected sexual contact with someone who has an STI, regardless of gender, sex or orientation.
Myth 3: You can't get an STI from oral sex.
Yes, you can. You can get an STI from oral, anal and vaginal sex, as well as genital skin-to-skin contact. Some STIs can be spread through contact with bodily fluids such as semen, and HIV and hepatitis B can be spread through blood.
Myth 4: A condom protects you from all STIs.
"One misconception I see is that if you use condoms, you are 100 percent safe from infections," Montes said. "Unfortunately, certain STIs such as HPV can be transmitted with skin-to-skin contact alone, so while condoms are very good at reducing your risk, they are not 100 percent protective."
Myth 5: If you don't have symptoms, you don't have an STI.
"Many people believe you know you have an STI because you can see warts or discharge," Croft said. However, many people carry STIs and have no symptoms at all.
While these misconceptions are among the most common, you might have heard others. If you're unsure about the information you hear about STIs and STDs, speak to your healthcare provider and ask them to explain anything you don't understand. It's better to get the facts and stay sexually healthy.
How to protect yourself
"You and your partner should be screened before entering a new sexual relationship," Montes advised.
Croft added it's wise to insist on using a barrier method (such as wearing a condom) when having sex with a new partner.
"Remember, though, that if you hear all your tests are negative, that doesn't necessarily mean you were screened for all STIs, including HSV and HPV," she noted, referring to herpes simplex virus and human papillomavirus, respectively.
You need to talk to your provider about testing. If you have a cervix, you should also address when you're due for your Pap smear, bearing in mind women older than age 30 can be tested for HPV.
Rymland stressed that though most people don't realize it, three-site testing—genital/urethral, throat and rectal—is essential.
"This is because certain STIs stay local in the throat or rectum, and if you only test for and treat genital infections, you'll miss the other STIs and pass them to partners who [can then] pass them back to you," Croft explained.
Many practices are taking steps to make STI testing more accessible. For example, Montes has partnered with the Body Agency and Visby Medical to improve STI screening at the border between the United States and Mexico in Arizona with Visby's sexual health kits. The kit is a single-use, rapid, nucleic-acid-based diagnostic test for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas vaginalis infection.
"It can detect three of the most common and treatable STIs in under 30 minutes. It is easy to use, and I'm excited to be a part of this women's health innovation," she said.
It's never too late to talk about it
Montes emphasized the importance of having conversations about STIs and STDs with children and teens, starting at a young age. She added that physicians also need to screen high-risk individuals and offer to test everyone even if they don't necessarily mention it.
"Talking about STIs can be difficult, so it is up to parents, physicians and healthcare providers to at least start the conversation," Montes explained.
"Consider how your future life might be affected by an STI," Croft said, noting that HIV is survivable but requires a lifetime of medication and medical management. Chlamydia is treatable with antibiotics but can cause problems, particularly with fertility, if left untreated. There are new strains of STDs that may be untreatable, such as super-gonorrhea.
"If you put yourself at risk of one STI, you put yourself at risk of all of them," Croft said. "Safe sex is the best kind of sex."
Rymland's last piece of advice, often overlooked, is simple: Talk about it.
"Talk to your partners about your status and testing schedule, and get tested together," she said. "Talk to your friends about STI testing. Normalize the conversation."