Destigmatising STIs Online Course:
Understand Sexually Transmitted Infections

Hello. I’m Dr. Evelyn Decker, a board certified family physician in the United States. I started my journey as a sex health educator when I recognized the importance of sexuality as part of our overall health. Throughout my studies in integrative, holistic and functional medicine, I was struck by the fact that sexual health and pleasure were never addressed. This omission propelled me to dive into the study of sexuality as a modality for wellness and embodiment. Sexuality serves for more than just the purpose of reproduction. In medicine, we only address sex when it's a problem. Yet sex is also a source of physical embodiment, pleasure, and deep connection with others. By recognizing this, we can start to change our relationship with our sexual health from being problem based towards being a source of healing and happiness. Sexually transmitted infections offer a classic metaphor for sex, disease and shameful. The traditional medical model, which only views STIs as a disease, is symptom, blames stigma and marginalization. This is especially true for people living with lifelong infections such as HIV or herpes and reinforces a negative relationship with our bodies and mental health. Instead, if we recognize that STIs occur much like any other infectious disease like influenza or COVID, but just within a sexual context, we can create a less shameful and sex positive understanding. A sex positive, holistic health care model empowers us to take better care of our health by having open communication with our partners and health care providers without feeling judged or shame because of our choices. Knowledge is power. I will also present a sex positive model for reducing the risks of besties. This starts by recognizing that sex is normal and healthy and part of what it is to be alive rather than focusing on changing behavior through abstinence, monogamy, condom use. This perspective gives you an agency over your own health care decision making. Having a better understanding of STIs can minimize STI transmission because. Because sex isn't something to fear, but something to value. I do come from a perspective of a medical doctor trained and practicing in the United States. All of my recommendations are based on medical literature, recommendations from the United States Center for Disease Control, the CDC, and ongoing education that I have pursued. I identify as consensually non-monogamous, queer and Latina. All of these biases must be taken into the context of my ideas and recommendations, which are my own, unless stated otherwise. Throughout this course, I strive to use language as respectful, accurate and maximally inclusive. I will say black people when referencing African-Americans and others that are part of the African diaspora. Latinxs For people who have cultural connections to Latin America, transgender nonbinary as an inclusive term that is intended to encompass nonbinary, gender fluid and other persons, LGBTQ plus refers to individuals who are lesbian, gay, bisexual, transgender and queer. I may to choose to use the term queer to signify all people who identify outside of traditional gender, sexual and relationship norms. I use inclusive and destigmatizing language when discussing sexual behaviors such as the use of barriers which represents condoms, or instead of using protection. I also use negative rather than the word clean and safer rather than the word safe. My use of anatomical terms such as people with vaginas or canals rather than female and people with penises rather than males to be inclusive of all gender identities and orientations of people. I use sexually transmitted infections instead of sexually transmitted diseases unless referencing actual diseases rather than the infections themselves. The term sexually transmitted infection STI refers to virus bacteria, fungus and parasites that have infected a person's body via sexual contact. Whereas sexually transmitted disease study refers to a recognizable disease state that is developed from the infection. Infections can be transmitted through sexual activity will be reviewed each in their own section. You will have a clearer understanding of the manner of transmission and the sorts of sexual activities that can contribute to being infected. And lastly, to all the testing protocols, I will conclude this course by discussing sexual positive paradigm for minimizing transmission. Rather than go over the same model used for decades of abstinence monogamy and condoms, I will introduce a new way to understand risk reduction This model through becoming aware of your risk tolerance. Understand handling your sexual networks and through clear and honest communication. I will introduce a framework for communication, costars, staff stands for STI transmission, turn ONS avoids relationship intentions and expectations, and how to create a safer sex container. We'll discuss briefly of what all this means. Welcome and thank you for being on this journey with me. Destigmatizing STIs using a sexual health positive framework. STIs represents an array of more than 30 viral bacterial and parasitic infections that are transmitted through body to body contact and therefore put into a specific category of sexual activity. For many, this may mean the insertion of a penis into another person's body, whether it be in a vaginal canal, a mouth or an anus. While this is one mode of transmission, some of the infections are passed through skin to skin. Daniel To genital or oral to genital. I am including the anus as part of the genitalia. I will not be discussing any other transmissions of these infections. HIV is the most feared of all the STIs, while chlamydia, gonorrhea and syphilis are the top of the list of the reported infections. Other studies of significance, such as human papillomavirus or HPV and herpes simplex virus, are not reported, so the true prevalence is not known. Messages are inherently linked to sexuality, which is fundamental to the human existence and a source of well-being and pleasure. STI stigma is directly related to how our society holds negative views of sexuality, particularly outside of monogamous, committed heterosexual relationships. As a result, discussions around sexuality and sexual health are avoided at multiple levels from within families, schools, and even to health care providers at a personal level. Societal stigma inhibits our own willingness to engage in health care needs. Many people avoid having conversations around STI and sexual health due to the inherent discomfort associated with them. Even our language reflects this when we tell others that our screen was clean. Rather than use the terms we would for any other infection such as negative or absent, clean reflects our own judgment and discomfort with how we present each other with our eyes. Using a framework of sexual health and wellness. We can shift our understanding from fear and shame towards pleasure and health, emphasizing health and wellness, focusing on creating consensual relationships and acknowledging sexuality and pleasure as an element of overall health. We can craft a holistic approach to prevention. We cannot have a discussion on sexual health with and its importance without recognizing the importance of pleasure. When we understand that pleasure air is an integral aspect of the human experience, we can begin to utilize it as a healing modality. Integrating sexual health into overall health, we can begin to create a more holistic understanding of sexual behavior outside of just seeing it as problematic. Approaching sexual health and STI prevention as part of holistic health and wellness helps us to better address personal, cultural and social determinants of health. In this manner, we create a more positive process, active and destigmatizing way of lessening the risks of STIs and minimizing their transition. Something that risks behavior modification through monogamy, abstinence and condom use has been unable to successfully do. At the same time, we move away from the shame and guilt over doing something that is inherently beautiful and gives us pleasure and joy. Herpes simplex virus has two main types one and two. They are part of the family of eight other herpes virus, which includes chickenpox, which is herpes zoster and mononucleosis, which is Epstein-Barr. This particular virus lives in a nest of nerves and supplies a sensation on your skin. Herpes type one mainly infects the head and neck, while herpes type two mainly infects the boxer short region of the body. That being said, herpes type one known as the cold sore virus can also infect the genital. When we speak of oral herpes, we are talking specifically about herpes type one because it is rare that herpes type to infect that region. When we speak of genital herpes, it can be either types one or two or actually even both together. Herpes type one or HSV one is far more common infection with close to 4 billion people worldwide infected with it. Infections for type one usually occur in childhood and the antibodies which are the cells created by our immune system to fight infections, can protect people from having severe genital herpes type two outbreaks and severe type one HSV two, on the other hand, infects about 4 million people worldwide. For the remainder of this talk, I will focus on genital herpes, which is a disease state caused by either types one or two. While it is possible to be infected by both, it is extremely rare since the antibodies of one protect you from the other. Since both strains can cause genital herpes, what is the difference? The outbreaks from genital herpes type one tend to be less frequent, less severe, and may be reduced to nothing over several years. Type two can have outbreaks 4 to 5 times a year and they could last for decades, but often also become less severe over time. I will not be discussing herpes that is obtained through pregnancy or what we call congenital. I will only be discussing sexually transmitted herpes. You can't get infected with this virus through skin to skin or mouth to skin. One can also self infect with a cold sore on the mouth going to the genitals. Herpes is the most contagious during in a rash outbreak. Direct mouth or gentle contact with the sore, which looks like a blister or even an open ulcer. Transmit viral material from one person to another. The second most contagious time is the period right before the rash shows up. And that's called the program. Up to half of people who have genital herpes have time right before their outbreak where they could feel the virus traveling down a nerve. This can feel like a burning, tingling or heat in their boxer short area. Being aware of these warning signs can lessen transmission because then, you know, to avoid skin to skin contact during this period. Also, if somebody is having an outbreak in their mouth or they feel their tingling, avoiding mouth to genital transmission can help. It can also be spread when it is dormant and not visible or right before an outbreak. This is what is referred to as shedding. Shedding is when the virus particles replicate and then travel from the nerve bundle they are living in down to the nerves of the skin. Shedding is unpredictable and occurs most frequently within the first few years of getting the infection. While this may seem frightening, shedding can last anywhere from a few minutes to a few hours and even two days. But can be reduced through healthy immune system and antiviral medications such as acyclovir and valacyclovir. People with vaginal canals get more infections that people with penises. This is because they have more of a mucosal surface. In one study of heterosexual monogamous couples where one person had genital herpes and the other did not. The one year transmission rate from a penis to a vagina was 9%, while the other way around from a vagina to a penis was 4%. These rates are for people who do not use barriers or any antivirals. They just avoid a contact when they felt an outbreak was going to happen. Using barriers reduces the risk by 50%, and then antivirals can reduce the risk by up to 80%. Genital herpes can range in symptoms from severe burning and pain to nothing at all. If a person got infected without having any prior infection, no cold sores, then the first outbreak usually occurs between one week to six months after contact. The initial outbreak is often the worst, especially with people who never had had contact with the virus. It feels like a flu. You get fever, body aches, followed by itching and burning and painful blisters in their boxer shirt region. If a person has herpes type one and has developed these antibodies, the cells that fight the infection, then the infection could be very mild or even asymptomatic, and it might even resemble other infections such as a urinary tract infection or rectal fissures. This is especially true if the outbreak is inside of the journalist, the urethra or the anus and not visible by a rash on the outside. Up to 80% of herpes infections fall into this category, with 60% being mild or thought it was something else and 20% are asymptomatic. Unfortunately, these people still shed and might pass it on to someone else unknowingly. To keep this all into perspective, though, another virus that acts very similarly is herpes, zoster otherwise known as chickenpox. Even if you contract this during childhood, the virus lives forever in a nerve bundle. As natural immunity weakens with age. This virus can present itself very similar to genital herpes, but in a different area of the body, and usually only on one side. This is called shingles. I have thinking of on the general region. Yet we are not frightened of shingles or feel ashamed of it, since it does not carry the stigma of sexual transmission. There is no cure for herpes, however, but there is some antiviral drugs that can help reduce or prevent symptoms. A cure for herpes is still years away, but there is research using gene therapy, vaccines and immunotherapy in the works. First and foremost, an important way of minimizing transmission is through communication. I'll repeating this throughout the class. Asking about a person's sexual history and health can help us make better informed choices. Having these conversations early in the relationship and not right before sex or the night of is the best way of going about this. The next way of reducing transmissions is to understand herpes better. There are patterns to most people's outbreaks, and the better someone understands their body, the less risk they have of transmitting it. Yes. Trust your body. There is no reason to avoid sex with others if you have herpes and no reason to avoid sex with somebody with herpes. If you understand that all sex is risky and relationships carry lifelong baggage and that many people who are partners with herpes do not actually ever get it transmitted to themselves. If you are in a sexual relationship or intimate relationship where one person has herpes and the other doesn't. The steps to reducing transmission are one. Using an antiviral such as a cyclo beer or valacyclovir. This can be used every single day, or possibly four days before contact. Although there have been studies referencing that too. Keeping a program diary so the person with herpes can better understand their body and their triggers. Three. Avoid skin to skin or skin to genitals. Mouth to genitals. Mouth to anus. Contact during prodromal outbreaks and this goes for herpes type one cold sores as well for using barriers such as internal or external condoms, dental dams, latex underwear, or 3 to 4 layers of non microwavable safe non microwave safe plastic wrap. And lastly five. Keep your immune system strong with stress management, good sleep and nutritious diet. One can also explore intimacy without genital contact such as sensual massages, sensation, play bondage, or many other forms of sexual activity does not mean having to put an infected part upon somebody else. This can be really helpful when the risk of transmission is unknown or higher. There are two ways to check for herpes. One gives you a diagnosis and the other one tells you if you've been infected by the virus. Neither tests as part of a routine STI screen, and I will discuss the reasons why the gold standard of diagnosing herpes with somebody when they present with an actual outbreak. This is the disease state is Q-Tip swab is used on the lesion and then sent to the lab for confirmation. The results will tell you if it is herpes and what type it is. Some people actually never get the test and just told that they have herpes by the way it looks. I would recommend getting tested since it could tell you a lot of what to expect. Since type one is less severe, sheds less and has a decreased risk of transmitting it to other people. The other test is the blood test to check for antibodies that are created in response to an infection with herpes. Many people think this is included in their routine screening, but it is not. In 2016, the United States Preventative Health Task Force recommended against routine screening due to its high false positive rate and belief it would cause more harm than good without causing any changes in sexual behavior. I personally disagree with this perspective because it invalidates our agency for our own sexual health. Yet that is the standard of care in most countries. The antibody test definitely has its limitations. Most health care providers are trained in understanding the test or in counseling people with positive results and what to do and how to proceed. Many people with positive antibodies will actually never go on to have the rash or disease sent. We have no studies knowing if these people who have positive antibodies but no rash ever shared and whether or not they can transmit the virus without genital herpes. But we must assume that it is possible. We also have no way of knowing whether herpes lives where it lives. For example, if you have a positive herpes type one does, it doesn't say if it's in the mouth or if it's in the genital region. Therefore, while this test can tell you that you have been exposed to herpes and have created the antibodies or were political soldier cells, it doesn't tell you that you will pass it on to anybody. Remember that most people who get the disease will get it anywhere from up to a few weeks to six months after exposure. That being said, the serum antibody test is recommended in the following cases. One. Recurrent genital symptoms such as urinary tract infections, vaginal itis. Proc. Titus, you're arthritis, Rectal pain with a negative workup and a negative swab test. A visual diagnosis of genital herpes. But no laboratory confirmation. Someone who has had lesions but never swabbed it might be able to help differentiate the two types. Three people who have had a partner vaginal herpes, but have never had any symptoms. They may want to know if they've developed any antibodies to it. For people with multiple sexual partners, the CDC, the CDC defines this as more than four partners. I don't know what four means. Is a foreign one lifetime or four at the same time. Because of that, I often recommend that people who practice non-monogamy to have this test and to let their health care provider know that this is a recommendation for them. And lastly, people who have HIV. So what do you do if you have a positive test or have herpes? Letting someone know that you have genital herpes or hearing someone tell you this can be laden with shame and fear. Many people, when they first get the diagnosis, feel an enormous amount of fear that they are now marked for life. There's shame around how they got genital herpes can affect the way that people feel about their own sexuality and intimate relations with good support. Understanding of herpes and body awareness. These fears may be laid to rest. Some people with genital herpes let people know right away before they invest in a relationship. Others wait until they've created a safer container or they know they want to move into deeper intimacy. Both approaches work. Not disclosing doesn't do people with knowledge and all herpes need to disclose? In my opinion, yes. Because this then allows open communication, consent and informed decision making. Cold sores can lead to genital herpes if not careful, but awareness will help reduce the chance. The bigger and more complicated question is what to do with people with positive antibodies but who have never had a gel herpes outbreak. This complication is why the CDC does not recommend this test. It is, in my opinion, to let potential partners know that you've been exposed to a herpes but never actually broke out. The risk of transmission is unknown. So depending on the needs and risk tolerance of each person, you can proceed as if you have genital herpes. Or take a wait and see approach. Understanding that there is a high false positive rate to the test. The use of antiviral medications in asymptomatic, asymptomatic people is of uncertain value, but if you have a low risk tolerance, then I recommend that you take it. What do you do if someone discloses a positive status? It can be hard to hear that someone tells you that they have genital herpes. A positive antibody tests IRL herpes. It can lead to a lot of fear and pulling away. In my opinion, it's just another infection that we can give to one another. It may not be pleasant to get. It may be hard to live with knowing you could pass it on. But the more knowledge you have around genital herpes, the better informed you are to make that decision. Things to ask for. How long have you had genital herpes? The longer a person has had it, usually the less outbreaks and shedding they have. What type of genital herpes do you have to have? Type one or two Type? What has less risk of transmission? So it's good to know the difference. How often do you have an outbreak? This too, can give you an idea of how active the disease state is. Do you know your triggers and procedure? When someone knows their body well, they know how to be and when not to have contact with other people. What do you do to reduce outbreaks? Do they take care of themselves? Do they do good stress management? What's their diet? Are they on antivirals or supplements that work for them? Lastly, how do you feel about using antivirals and barriers such as condoms? Taking a daily antiviral can reduce transmissions by 50% and barriers by another 50% and shedding to 80. Gentle herpes can be a life changing infection. That doesn't mean it's all negative. Many people with genital herpes are far more aware of their body and committed to not passing it to others. The key is open and direct communication. With this, the risk of transmission is significantly lessened. Instead of coming from fear, we could come from an approach that is sexual health positive and validates our needs for sexual intimacy and wellness. HPV human papillomavirus. HPV is the most common STI in the world in the United States. Data from early HPV vaccine trials suggest the lifetime prevalence of the infection is 85% in women and 91% in men who have had at least one sexual partner. There are more than 200 strains of HPV, of which 40 types are considered to be STIs. HPV is silent and can resolve without ever knowing it was there, or it can show up as genital or anal warts. In its worst case, it can progress to cancer. HPV cancers are located in the cervix, which is that opening of the uterus and located at the end of the vaginal canal. The esophagus, which is in the back of your throat, the anus and the vagina. HPV strains are divided into low and high risk types based on this likelihood to progress to cancer. Low risk types cause warts and low grade cellular changes. While the 15 high risk types are associated with cancer of the cervix, anus and throat, HPV is spread through direct contact between genitals, genital to cervix and mouth to genitals, cells spreading from genitals to anus and with the use of a barrier. Sex toys between people can also occur. The cervix is the primary place for high risk. HPV resides and progresses to cancer. HPV especially infects people with cervix is in their teens and twenties because the cells are changing and growing so rapidly that one can get infected with different strains throughout their lifetime. And it takes about 10 to 20 years from an infection to actually see cell changes and it progressed to cancer. Having one strain does not protect you from another. You can not get reinfect it from the same strain once you cleared it. But since HPV is can lay dormant for years, it may not show up on testing until later in life. An active HPV infection is believed to be transmitted to another person through direct contact with a penis, mouth or toy from one person to another. It is extremely rare to get HPV on a cervix and have it progressed to cervical cancer after the age of 65. Since by then most people have already had had it and our immune to it. The esophagus is another area of HPV related cancers. It should be esophageal cancer is usually recognized after the cancer is removed and has been tested. There are no screening tests for this. A history of smoking or having a penis increases the risk for this cancer. Luckily, HPV esophageal cancer has a better response to treatment and is often not fatal. HPV can be asymptomatic and only found upon testing, or it could show up as warts on the outside of the genitals and anus. These words can be a single or clusters. They can be flat or look like cauliflowers. They can be flesh colored or gray. HPV infections in the cervix, throat, anus and vulva and vagina have no feeling to them at all and are usually microscopic. There is a long latent period of 10 to 20 years between cervical infection and the diagnosis of cervical cell changes. With the incidences of cancer peaking at 40 years of age and HPV infection found at the age of 35 could have been from an infection in their twenties. HPV has no cure, but 90% of the infections clear by themselves within two years. Cervical changes, which can occur up to 20 years after infections are graded from 1 to 3, depending on how much they've been affected by the virus. Levels one and two often regress without any treatment. However, if the infection does not clear after two years, it is more likely to progress to a higher grade lesion or to cancer. Cervical infections are either followed through yearly testing or if the cells show any precancerous changes by freezing or removing parts of the cervix. When HPV shows up as warts, they can be removed by freezing them, burning them, or most usually by a topical cream that you could do at home. The best way of preventing HPV infection is by being vaccinated at a young age. In the United States, it's recommended to be vaccinated between the age of nine and 15. It is best to get vaccinated before sexual activity starts. So that the body has fully formed immune system before it can be introduced. There are three different types of vaccinations available and only one is currently in use in the United States. One of the vaccines which can be found in Europe protects only against the two most high risk strains Type 16 and 18. There's another one that protects against four and the one that is currently mostly used Gardasil nine protects against seven of the high risk strains and two of the low risk wart strains. They provide about 90 to 100% protection against the strains most likely to lead to cancer. If you did not get vaccinated, adolescents in the United States, you could still get the vaccine up until the age of 45. People who might qualify are those at risk of being exposed to new HPV infections or immunocompromised. Keep in mind, HPV vaccines prevent new HIV infections, but do not treat existing ones, nor the disease. Most sexually active adults have already been exposed to HPV, although not necessarily all of the types targeted in the vaccine at any age. Having a new sex partner is the risk factor for getting a new HPV infection. While one can use barriers such as internal and external condoms to reduce transmission, they are not 100% effective. Since skin on skin contact can also lead to HPV infections, can you get the vaccine over the age of 45? Yes. But you may have to pay for it since it's not approved for that age group. It will not cause you harm to get the vaccine, but may also not protect you, since you may have already gotten all the strains previously without knowing it. HPV related cancer is the highest in people over the age of 35 and peaks around 50. Most of those who were infected and have cancer happened when they were in their twenties. HPV is not part of a regular STI panel at this time. HPV testing is only done on people with the general canals and services. There is no test available for penises or any screening test at this time available for throats. Anal testing is controversial and currently not recommended unless a person has HIV or changes in the tissues or a known contact with somebody with a high risk HPV through genital to anal contact. To check for cervical infection, a swab of the cervix must be obtained starting at age 21. It's recommended to have a cervical exam for abnormal cells, which is called a pap smear. These tests are done every three years until the age of 30. Then afterward, every five years, HPV testing is started at 30, along with the PAP test. HPV is not checked before the age of 30 because it could lead to further invasive procedures. And most of the time it clears by the age of 30 years old. HPV tell somebody if they're negative or positive, if it is positive. Further testing can be done to see if the strain is high risk. They can lead to cancer or a low risk one that can lead to walk or mile cervical changes. While some cis women and transwomen don't have cervix is, they may still need a pap smear to monitor the health of their cells. This is especially true if they've had a previous HPV infection and the tissues that make up their new vagina, or if they had an HPV and in the tissues prior to the removal of the cervix. External HPV Visible as words are diagnosed through visual evaluation, it is often challenging to get a diagnosis of an infection that could have been present for many years and then known to everybody. When a person with a cervix has an abnormal PAP or a positive HPV on their testing, it is important that they let any current sexual partners know. But that partner may not have given them the infection. Nor is there any way of knowing if they too are infected without a pap and an HPV test which aren't available to people with penises since this infection is ubiquitous. It is believed that most people have contracted it with some one some time in their past for a low risk HPV infection. A thorough visual examination towards or other lesions can be done for high risk HPV. It is impossible to know of a partner with a penis is infected or not, or if they can unknowingly pass it further on. This dilemma is difficult and there is no one right way to be 100% certain that it can be contained. I recommend anyone who is sexually active with more than one person be vaccinated. While it won't prevent infections with strains already exposed to, it will help reduce infections and strains that have not. HPV is the common cold of ashes for a vast majority of people. HPV clears without ever knowing they had it. Most of the infections clear within two years. For the few that don't. Ongoing examinations and treatment may be needed. The progression to cancer from the cervix vagina anus is rare when good follow up has been done as I said previously, throat cancers that are HPV positive tend to be more treatable and less lethal. External HPV is also treatable and resolved through time. HPV can be more of a nuisance than a life or death or painful experience. As with all viral infections, one's immune response goes a long ways. That is not to say that someone with cervical cancer made poor life choices, but it can help to reduce or avoid cigarets nicotine help to have a good, healthy diet, such a mediterranean diet or a plant based diet, and also to reduce stress through meditation, good sleep, pleasure and exercise. Gonorrhea, also known as GC, and chlamydia, are both bacterial infections that are lumped together. Gonorrhea got its name from a cloudy discharge that often accompanies it. Gonorrhea and chlamydia act like siblings and one can increase the risk for the other. In fact, testing is often done at the same time, both gonorrhea and chlamydia are the most often spread through direct contact from genitals and for mouth to genitals and even spread from vaginas to anuses. They can also can be spread through shared sex toys that don't have condoms from one person to another. Chlamydia is very highly transmittable. If one person has it, there's over a 50% chance that it will be given to another partner. Chlamydia could become a chronic infection that lasts for months to over a year if left untreated. Gonorrhea is also highly transmittable and can be found in the or canal throat and anus. Transmission to the throat from oral sex with a penis is higher than oral sex with a vulva. An infected throat can also pass gonorrhea to the urethral of a penis to an anus and available to oral sex. Young adults have the highest risk of a chlamydia infection from a combination of biological, behavioral and cultural reasons, which include abstinence based sex education, poor access to barriers such as condoms and difficulty getting tested. Biological factors include the the maturing cervical cells. A young adult are really susceptible to this bacteria. Oral contraceptive pills also make it more susceptible. Both infections can have very similar features, but gonorrhea has a milky discharge similar to semen. In fact, the name comes from Greek word Gano means seed and means blow. And people with penises. Urethral infections are the most common. Often these infections, especially the ones with chlamydia, can go unnoticed or have a clear discharge. Gonorrhea infections of the urethra tend to be more symptomatic with the cloudy discharge and pain with urination. So it kind of feels like a urinary tract infection. Chlamydia can also infect the area inside the scrotum called the epididymis. This shows up as a one sided pain in the testicle with tenderness and swelling. Infections in the anus are common with gonorrhea, especially with bottoming. Discharge Pain with pooping are the most common sides of being infected. Rectal gonorrhea can also increase the risk of HIV and people with vagina. Cervix is an uteruses. These infections can show up in very similar ways, but chlamydia is often less noticeable and could remain silent. The main complication of both these bacteria is the deep infection into the uterus called pelvic inflammatory disease. If left untreated, 10 to 20% of chlamydia infections can lead to it, which can cause scarring of the fallopian tubes. 20% of people treated for PID become infertile. 30% develop chronic pain. And those who do end up conceiving and about 1% can have an atopic pregnancy or pregnancy in their fallopian tubes. Chlamydia can also show up in anyone as an infection in the eye throat, lymph nodes post and fragmentary autoimmune. Arthritis called Ryder Syndrome is a very rare infection, even in people who have been treated for chlamydia and gonorrhea. Gonorrhea is very similar. It could show up in the eyes and throat and even become disseminated in the whole body. But that is extremely rare. Now that I scared you, both of these infections are easily treatable with antibiotics. Calamity is treated with an antibiotic. Products recycling and gonorrhea with an injection of subtraction, which is related to penicillin. There are other antibiotics. If somebody has an allergy to penicillin, often both are treated at the same time. Since they are bound together. Routine testing is done through urine or through a direct swab in the vagina, in the throat or the anus or also in the urethral area of a penis. Testing should be done everywhere there has been unburied insertion or contact with genitals through a shared sex toy. It is recommended that people with cervix get tested yearly from the time of first sexual contact until the age of 25. Even people with cervix who identify as gay, lesbian, trans binary are recommended to have yearly testing through this age, since an infected partner can pass the through on barrier sex, toys or oral sex, it can take up to two weeks after an exposure to come back positive on a test. I also recommend that everybody be tested before any new sexual partner. When barriers will not be used, if that does not occur, then test soon afterwards. It is important to test regularly and share these results in situations of serial monogamy and non-monogamy. In the United States, gonorrhea and chlamydia are infections that get reported to public health departments often. They notify all infected partners and check in with the treating health care provider to make sure that everybody has been treated correctly. It is very important that if you've been diagnosed with this infections that you disclose to all known sexual contacts as soon as possible. This will aid in the quick treatment and minimize ongoing transmission. If you are not sure of a partner status and want to be covered, it is recommended that you take doxycycline within three days of exposure to help reduce the chances of getting chlamydia. There is some evidence that gargling with Listerine can help reduce oral gonorrhea, but on other studies it doesn't show that it helps at all. I don't have any further recommendations on how to reduce oral gonorrhea other than good hygiene and testing. There is some known antibiotic resistance to gonorrhea, so testing and prevention are the best ways. When gonorrhea and chlamydia are common infections. These trends transmissions can be so great they minimize to regular testing the use of barriers with partners that you don't know their STI status and to clear communication. Human immunodeficiency virus or HIV is a virus that attacks the immune system, which then allows other infections or cancer to harm the body. HIV is the infection and acquired Immune Deficiency Syndrome, or AIDS is the disease. AIDS occurs when HIV is left untreated to the point that the immune system fails. While HIV like herpes, is considered incurable, except for three reported cases, there are safe and effective medications to help keep the levels of HIV in your body very low and people can live a long and healthy life. HIV is spread by certain body fluids and blood to unburied anal or vaginal sex, sharing needles and rough sex that causes bleeding. HIV is found in the blood, come pre come rectal fluids, natural fluids and breast milk. HIV can live in a used needle for up to 42 days. So sharing needles or other equipment to inject drugs and medicines, even under the skin, can be a source of infection. There are different risk levels involved with sexual activity, receptive anal sex or bottoming without the use of barriers is a high risk sexual activity. But you can also get HIV from insert of anal or topping. Either partner could get HIV through vaginally sex, though it is less risky than anal bottoming. There is a very small chance of getting HIV from oral sex. Usually if the giver has mouthful sores, sores or bleeding gums. A person with active herpes also has a higher chance of getting HIV, just as a person with HIV has a higher risk of getting herpes and gonorrhea. There is a very low transmission through fingering or fisting unless are open source being very rough and causing bleeding increases the risk. If you have sex later, HIV is not spread through touching saliva, tears or sweat. Unlike COVID 19, sneezing does not spread HIV since it's not a respiratory virus. HIV does not survive long term outside the body and cannot multiply outside of the human host. People who have multiple partners for anal insertion with the penis are at the highest risk. Use of a condom for penetrative sex, avoiding contact with bodily fluids, knowing your partner's status and clear consent and understanding for rough or higher risk sex play spermicide do not prevent HIV and they should be avoided because some spermicide may actually increase the risk of transmission. Lubricants contain a known arsenal. Nine should not be used because it can irritate the lining of the vagina and anus and increase the risk. Washing after sex, taking herbal remedies and pulling out do not reduce transmission and should not be relied upon if your sex involves higher risk activities. There are medications that can greatly minimize the risk of transmission. First, anyone who has HIV should be on antiretroviral medications. These medications are very effective at reducing viral load, so the amount of virus that is in bodily fluids goes to undetectable levels. Undetectable equals one transmittable. This in of itself has been a life changer. Yet one cannot always rely on another person to do all the work. Therefore, higher risk sex participants can be on medications as well. This goes by the word prep, which stands for pre-exposure prophylaxis. These medications can reduce the risk of getting HIV through sex by almost 99% of taking correctly. Prep can be obtained through a health care provider. HIV is almost always included on an STI screening panel. The recommendations from the CDC is to have at least one test in a lifetime. Of course, this assumes low risk sex with only a few partners during a lifetime to with people who have sex with a higher risk of possible transmission without the use of antiretrovirals or prep. I recommend every three months or 3000 miles, whatever comes first. People who are currently on Prep are tested regularly every three months. If someone isn't sure if they were exposed first test four weeks after possible exposure. If the first test was negative, recheck three months later as a confirmation. There are medication regimens to reduce the risk of getting the virus as exposure was unknown or inadvertent. This is called post-exposure prophylaxis. This regimen of medications needs to be started within three days or 72 hours and continues daily for one month. Like all lists, this clear communication is the key here. The elements that should be shared are not just status, but if medications are being used and how regularly they are being taken. Just because someone is on an antiviral retroviral therapy does not mean that they have undetectable viral levels. Just because someone is on prep doesn't mean that they don't have any other STIs. While HIV has gone from a death sentence to a chronic infections does not mean that all bets are off. People with HIV are at higher risk for the other sites, including herpes. The use of barriers is always a smart recommendation when it comes to minimizing transmission, especially if you just met a new partner or haven't had a recent STI screen. Like the other viral STIs, there is a lot of fear and stigma attached to living with HIV. Our language can better reflect that HIV or any other chronic viral infection does not define a person or their life. Living with an STI does not make that person mean that they made a bad choice or did something risky or foolish. Interacting sexually with others always comes with risks. The best we can do is to be aware, communicate clearly and treat others with compassion. We have been taught that preventing STIs relies on three elements abstinence, monogamy and condoms, which is often called protection. We are taught that we need to be free of STIs. We should modify our behavior to meet these standards. When someone ends up with an STI, we blame ourselves or others for not being able to follow these recommendations, which then can lead to stigma and shame. What we have been taught about STI prevention is not based on sex being something fundamental to the human experience. It is based on our culture. That prides abstinence and monogamy over self-expression and pleasure. What if instead we removed the need to modify our behavior and took responsibility for overall health? Sexual health is not a separate entity. It is part of one's own health and wellness. Sexuality is an essential part of being human, regardless of any activities you do with others. We are gifted with the fact that sex can bring us pleasure, connection, embodiment and a sense of wellness. Through this lens, we can take responsibility for self-care and extend that to also taking care of others. From this perspective, I will introduce to you three new elements to minimize as child transmission. The first is risk awareness. The second is understanding your sexual networks. And the third is communication. It is hard being human, and the trauma we experience and witness can be difficult to navigate. We tend to want to avoid anything that would increase our suffering. And this forms the basis for our tolerance for taking risks. Our risk tolerance varies along our life path. It is formed through complex and multi-dimensional forces that are uniquely our own. These factors are layered upon one another, like the skin of an onion. The center is ourselves, our biology, anatomy, hormones and preferences. The next layers are through our relationship with others. The nature of these relationships and their influences on us. Our home life represents the most basic of all attachments. The way we navigate our earliest life and what we learn about safety at home can be the first place that we imprint our relationships with our body and sexuality. Our community as the next layer. Within our community, we explore cultural values and norms and belief systems. The lessons we learned there can either help, hinder or help our sexual development and our ability to navigate safely or trauma traumatically. Societal influences determine the availability and quality of sexual education. Our resources to health care, as well as our unconscious biases that play into public health care measures. Lastly, the collective influence of the world's at large at any given moment also plays a role in our tolerance for risks. A person's individual health, plus the relationships they have with others, is strongly influenced by family, community, society and the collective global situation. The influence of others plays into our needs for oneself. We do not make choices based on being told to necessarily behave in any particular way. I use the metaphor of a backpack. This is discuss how these influences play a role in our choices to minimize risks, especially as high risks in this case. In a backpack we carry all the supplies that we perceive that we need for our survival. Everything that's contributed to our need for safety, from the personal to the global goes into this backpack. When that backpack is full, it can be almost too heavy and hinder our journey. If the backpack doesn't have enough, we may not have the tools that we need to keep us safer. I like in a heavy backpack with a low tolerance for risk and a high anxiety fear and tendency to avoid a lighter backpack signifies a high tolerance for risk and possible injury. The backpack analogy shows us how we relate to risks involved with any behavior by addressing the things we put into it. We can better understand what we actually need to keep us healthy and well. And then what doesn't serve us sometimes who compromise our health and safety for pleasure, while other times we restrict the possibility for joy due to fear and trauma by having a risk awareness. We can make better choices for ourselves and those we interact with. All sex is risky. The best we can do is make informed choices. The more we are aware of our risk tolerance and the factors that are affected, the better we can understand the choices that we make. For some, this may translate to sexual activities. For others, it can affect our choice of partners. Our sexual behaviors are variable amongst us, and there is no one way to act correctly. The second element to help reduce STI transmission is to understand that you live within a sexual network. We all live in relationships to others, as we have learned through the COVID pandemic, Considering the people we interact with helps us understand and reduce our infection risks. A sexual network acts in much the same way. It's something we have not been taught to think about or consider. The reason that two of the three recommendations of SGI prevention are abstinence and monogamy is because it closes the circle of transmission and makes a sexual network consist of only two. Unfortunately, those recommendations are not realistic for everyone. People who are monogamous but not in a relationship that lasts their lifespan forget that they too are in a sexual network with others. When one relationship ends and a new one begins that continue as a possible line of transmission for others who are not mutually monogamous relationships. The vector transmissions can be even larger by recognizing that we act within a network to others, helps as become responsible for our own self-care and the health care of others. Regular testing and barriers can all help minimize transmission. Testing for Chlamydia, gonorrhea, HIV Syphilis is recommended before any new partners, or at least annually, for non-monogamous people, or, as I like to say, every three months or 3000 miles. Whatever comes first. People with vagina's and cervix needs to be tested for gonorrhea and chlamydia every year from the start of any sexual activity through age 25. Communication of test results, as well as desires and boundaries is also critical. There are a number of ways to do this, but following a script can often be helpful when you're no added. One framework for a safer sex conversation is the star's talk. Stars is an acronym that stands for Sexual Health STI Status. Turn ONS avoids releases, ship intentions and expectations, and safer sex container. For the sake of time, I'll focus on the very first and last sexual health and safer sex containers. Disclosing STI status can be challenging at first if you haven't practiced it. I recommend starting with your own status and disclose this before asking anyone for theirs. This could sound like this. I was last tested for gonorrhea, chlamydia, HIV, syphilis in April. My results were negative. How about you? A safer sex etiquette is a great place to discuss one's sexual network and ways of reducing transmission so that you could co-create a safer container together. The use of barriers. Types of sexual activity. Risk tolerance can all be folded into this conversation. It can also be worthwhile to discuss what would happen if a transmission occurred and how one would want to be told and what else. Who else may be affected. Doing a star's talk is a perfect beginning to any intimate relationship, but it can also be done within any time in a relationship. Relationships tend to shift and change, so remembering to keep up and knowing and check in with a person is so important. And this is not only important for our own wellness and health and pleasure, but for each other. Sexually transmitted infections are part of being a sexual being. As we navigate intimacy to play and pleasure, we have the tools available to us to minimize the risks of getting sick or giving an infection to others. I say minimize because prevention implies perfection, and that stigmatizes those living with an STI. We can minimize infections by first by understanding them. Herpes, human papilloma virus and HIV are all viruses that remain in our bodies. Gonorrhea, chlamydia and syphilis are bacterias that are treated with antibiotics. But we can't get re-infected. Sometimes these infections show up problematically with painful lesions, can lead to cancer or destroy our immune system. But more often they are silent or easily controlled, with medications having a greater understanding of the true nature and risks of these viruses and bacteria that can help minimize the stigma and fear around them. This allows us to navigate our own sexual health needs clearly without marginalizing others. Risk awareness can also help us understand ourselves and others without judgment. Everyone's tolerance is created through a unique set of experiences that are layered upon one another. Biology, culture, values, trauma, and a collective global energy all play a role in how we navigate or tolerance for risk taking. Aligning ourselves together in this manner can help reduce stigma and shaming those who carry lifelong viruses or those who have a low tolerance to exposing themselves due to a multitude of factors. Understanding our sex networks encourage us to be proactive. Test, disclose and use barriers. This eliminates the stigma of being sexual outside of a mutually monogamous lifelong relationship. Lastly, communication is key. Open, honest, conscious conversations about our needs, desires, boundaries, sexual health will keep us all safer. Learning and practicing a framework such as the Stars talk helps us remember the five important topics to understand about ourselves and others our sexual health, our turn ons, or avoids our relationship trip intentions and expectations and our sexual health. Together, we could start navigating our preferences and our sexual health with others, as ties are a small part of our overall sexual experiences, and they can be minimized without marginalizing shaming and stigmatizing others for something that brings us pleasure, joy and connection. Thank you and I hope you have a beautiful and healthy and pleasurable sex life.