為何性傳播感染無法擺脫汙名?

資料來源：Jen Gunter，紐約時報，財團法人台灣紅絲帶基金會編譯

 

我們生活在一個性積極的時代 – 直到我們獲得陽性的測試結果。這很不幸，因為性傳播感染正在崛起。

 

圖片來源：CreditCreditIllustration by Claire Milbrath

 

作為一名產科醫生和婦科醫生，我在社交媒體上收到了很多恐慌的電話和直接信息 – 有時來自熟人，有時來自完全陌生的人 – 關於婦科問題。子宮頸抹片檢查結果、錯過的經期和熱潮紅是我日常的生計。同樣常見的是：墮胎流產的併發症、保險套漏失和食物誤入歧途（陰道）事故。

我認為人們會直接聯繫我是因為他們並未聯繫其醫療保健，因為他們很尷尬，並且（錯誤地）認為他們是唯一經歷過這種不幸事故的人，或因他們擔心他們的醫療提供者會做出批判（遺憾的是，這並不罕見），或因為網上有很多錯誤的信息，很難將好的與壞的分開，或僅僅是因為他們真的很害怕即使是在凌晨3點，也或許是因為我會回答。

我很自豪人們向我傾訴，不僅僅我是一名醫學專業人士，而且還是一個不帶批判性的人。幾乎沒有任何東西會在離開桌面後會被私下討論。

除了一件事：性傳播感染（S.T.I.s）。

在近30年的婦產科專業，我只有兩次在辦公室外面被問過。

似乎S.T.I.s是最後的禁忌之一。

（順便提一下，有些人 – 包括疾病控制預防中心 – 仍然使用「性傳播疾病」這個詞。但是，「性傳播傳染病」和「性傳播感染」也被認為是可以接受的。但我覺得在「疾病」這個詞背景下似乎意味著污名恥辱，這也就是為什麼我不使用它。）

我不需要告訴你，我們生活在一個容易獲得性的時代：春宮色情圖片只是一個點擊之遙，且往往是免費的。完整的正面裸露和圖形模擬的性愛場面是許多電視節目和電影的一部分。女性流行雜誌有關口交和肛交的明確文章。而人們在約會軟體上尋找搭訕或交往亦非常具體。

我想非常清楚，這一切都沒有錯。你喜歡你所喜歡的，無論如何選擇你的娛樂、你的幻想或你的性接觸方式。如果這一切都是雙方同意的，那一切都很好。

我們還可以更公開地談論性的其他方面，例如避孕選擇和墮胎（#ShoutYourAbortion是眾多的主題標籤其中之一）。然而，在性的傳播感染上似乎有一條強硬路線。

令人特別驚訝的是，性的傳播感染是無所不在的。如果我們思考到在美國有50％性活躍的人群到25歲時至少會有一項性的傳播感染（HPV是最常見的），並且在全美每年有超過1.1億新增和現有的性傳播感染的案件。人們顯然並不害羞地與我分享，所以唯一合乎邏輯的結論，就是性革命並沒有讓人們擺脫性傳播感染的羞恥和污名。

我看到這些反映在我的日常工作中。除了癌症之外，沒有任何的診斷可以像性的傳播感染那樣地讓女人流淚。特別是當它是皰疹。 （出於某種原因，但我不知道確切的答案，皰疹有很多恥辱。1982年，時代雜誌在封面上將其吹捧為「今日紅字」）。

在過去四十年當中並沒有太大變化。我一直是女性健康方面的專家，且專注於傳染病已有24年了，我對皰疹（或鞭毛滴蟲病或淋病或披衣菌 –像其他常見的性傳播感染）上的談話並沒有改變。

不知何故一種性傳播感染就會讓許多女人覺得好像是損壞了的貨物。在許多方面，我們的社會仍然認為女性在某個年齡之前發生性行為或者如果她們有多個伴侶，就會是「放縱的」。這種結構似乎永遠不直接適用於男性。在生育和妊娠上承擔性傳播感染後果的也是婦女。

病毒引起之性傳播感染的持續存在似乎打擊人們最深。對於你將永遠無法擺脫被感染的想法，對於許多人來說，是非常具有挑戰性的。

當考慮人類乳突狀瘤病毒（HPV，導致子宮頸癌和生殖器疣［以及一些陰道、外陰、口腔和肛門癌］的原因）的感染與EB病毒（EBV，與傳染性單核細胞增多症相關）的診斷相對比之反應時。在生物學上，這二種病毒非常相似。它們可以存在多年，在細胞中休眠。如果你可能的話，他們都可以重新激活 – 醒來 – 這會導致人們排放出病毒，從而在不知不覺中傳播病毒。

許多人甚至可能永遠不會知道他們什麼時候開始感染的，或如果他們確實知道但卻也是不知他們正在排放病毒，因此是具有傳染性。這種現象稱為無症狀傳播，是我們將這些感染傳染給其他人的主要方式。

（另外，人們通常不會故意傳播性傳播感染。例如，大多數人在有明顯的疼痛時都不會發生性行為，就像他們知道在嚴重流感時不會去握手一樣）。

儘管HPV和EBV之間存在基本的生物學相似性，但只有HPV與羞恥有關。 HPV是透過性、生殖器接觸和口交傳播的病毒，而EBV則是親密接觸和接吻而傳播。

為什麼從性生活中感染比從握手、親吻或咳嗽感染更可恥？為什麼生殖器皰疹是可恥的，即使有更多人有口腔皰疹（皰疹第一型），幾乎每個人都可以看到那些爆發流行？

我懷疑這是因為羞恥和污名是有效的控制武器，在歷史上它們一直被用來邊緣化女性、有色人種和性取向及性認同上屬於少數的L.G.B.T.Q. 族群之社群。在這些人群中，性傳播感染通常較高：生物學上的結合，因為大多數性傳播感染對子宮頸、陰道和直腸的傳播最容易；而且由於經濟上的邊緣化或偏見，傳統上這些群體中的人們獲得醫療保健的機會較少，這亦導致他們較少獲得篩查和治療。

在19世紀，當一個貧困的人患有「痘」樣疾病（梅毒或淋病；當時兩者之間並不存在著可靠區分之診斷）時，需要教堂執事公開之聲明以獲得協助。患有同樣痛苦的男女卻被送往不同的地方 – 婦女送到工作室，男子則到醫院。

當然，有錢的人可以完全避免公開地披露並獲得醫療保健。

在許多方面，公眾的羞恥和污名仍未改變。經濟上的劣勢使許多人無法進行篩查和治療，希望透過更安全的性行為保護自己免受性傳播感染保護的人 – 特別是那些性取向性認同非屬白種順式性別的異性戀男子（註：即性取向性認同非屬異性戀且為有色人種或少數族裔的男性）– 可以被錯誤地標記為淫亂的或骯髒的，或兩者皆是（無論這意味著什麼）。

這些話語可以經由他們的伴侶、他們的社區、線上陌生人甚至於透過與醫療保健專業人員侮辱性的互動過程中向他們拋出。

結果是許多性傳播感染正在上升。 2013年至2017年（數據的最後一年），淋病病例數增加了67％，梅毒增加了76％。

而且儘管H.I.V.的新感診斷比率穩定，在美國每年仍然都有超過30,000例新的H.I.V.病例是透過性行為而感染。其中幾乎每一個感染者都可以透過暴露前預防（PrEP）加以預防。唯一的亮點是由於疫苗的接種導致HPV相關的感染減少。

當染有一種性傳播感染應該與流感一樣有相同的恥辱，但實際上並不具任何意義。讓人們感到羞恥或批判他們的選擇，只是意味著讓他們更不可能會接受篩查、治療並獲得可以預防感染和挽救生命的照護。

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Why Sexually Transmitted Infections Can’t Shake Their Stigma

By Jen Gunter/ New York Times

 

We live in an era of sex positivity — until we get positive test results. And that’s unfortunate, because S.T.I.s are on the rise.

 

 

Image:CreditCreditIllustration by Claire Milbrath

As an obstetrician and gynecologist, I get a lot of panicked calls and direct messages on social media — sometimes from acquaintances, sometimes from complete strangers — about gynecological matters. Pap smear results, missed periods and hot flashes are my bread and butter. Also common: abortion complications, lost condoms and misadventures with food.

I think people contact me directly because they don’t have access to health care, because they are embarrassed and think (erroneously) they are the only ones to experience such a misadventure, because they worry their providers will be judgmental (sadly, this is not uncommon), because there is so much misinformation online that it is hard to separate the good from the bad, or simply because they’re really scared and it’s 3 a.m. and just maybe I’ll answer.

I’m proud that people confide in me, not just as a medical professional, but also as a nonjudgmental person. It seems that almost nothing is off the table.

Except one thing: sexually transmitted infections (S.T.I.s).

In almost 30 years of specializing in gynecology and obstetrics, I have been asked only twice about them outside of the office.

It seems S.T.I.s are one of the last taboos.

(Incidentally, some people — including the C.D.C. — still use the term “sexually transmitted diseases.” However, “sexually transmitted infectious diseases” and “sexually transmitted infections” are also considered acceptable. I feel the word “disease” in this context sounds stigmatizing, which is why I don’t use it.)

I don’t need to tell you that we live in an era of easy access to sex: Pornography is a click away and often free. Full frontal nudity and graphically simulated sex scenes are part of many television shows and movies. Popular magazines for women have explicit articles on fellatio and anal sex. People are very specific on dating apps about looking for hookups.

I want to be very clear that none of this is wrong. You like what you like, whether that is how you choose to be entertained, your fantasies or the way you engage sexually. If it’s all consensual, it’s all good.

We are also able to talk more publicly about other aspects of sex, like contraception choices and abortion (#ShoutYourAbortion is one of many hashtags). And yet there seems to be a hard line at S.T.I.s.

What makes this especially surprising is that S.T.I.s are so ubiquitous. Consider that 50 percent of sexually active people will have at least one S.T.I. by age 25 (HPV is the most common) and there are over 110 million new and existing S.T.I. cases each year in the United States. People are clearly not shy sharing with me, so the only logical conclusion is the sexual revolution stopped short of liberating people from the shame and stigma of sexually transmitted infections.

I see this reflected in my day-to-day work. No diagnosis, apart from cancer, can as reliably bring a woman to tears as an S.T.I. Especially when it’s herpes. (For some reason, and I don’t know the definitive answer, there is a lot of stigma around herpes. In 1982, Time magazine touted it as “Today’s Scarlet Letter” on a cover.)

Not much has changed in the last four decades. I have been a specialist in women’s health with a focus on infectious diseases for 24 years, and the conversations I have about herpes (or trichomoniasis or gonorrhea or chlamydia — other common S.T.I.s) have not changed.

An S.T.I. somehow makes many woman feel as if they are damaged goods. In many ways our society still thinks of women as “loose” when they have sex before a certain age or if they have multiple partners. That construct never seems to apply to straight men. It is also women who bear the fertility and pregnancy ramifications of S.T.I.s.

The viral S.T.I.s that persist seem to hit people the hardest. The idea of an infection that you can’t get rid is very challenging for many people to accept.

Consider the contrasting reactions to infection with human papilloma virus (HPV), the cause of cervical cancer and genital warts (as well as some vaginal, vulvar, oral and anal cancers), versus the diagnosis of Epstein Barr Virus (EBV), the cause of infectious mononucleosis.

Biologically the viruses are very similar. They can persist for years, hibernating in cells. They can both reactivate — wake up, if you will — and this causes people to shed the virus and hence spread it unknowingly.

Many people may never know they even had the infection to begin with, or if they did they do not know they are shedding the virus and hence are infectious. This phenomenon is called asymptomatic transmission, and is how we mostly pass these infections to other people.

(As an aside, people typically don’t transmit S.T.I.s knowingly. Most people have the decency not to have sex when they have a visible sore, for instance, just as they know not to shake hands when they have a killer cold.)

Despite the basic biological similarities between HPV and EBV, it is only HPV that is associated with shame. It is HPV that is the virus transmitted by sex, genital contact and oral sex, while EBV is close contact and kissing.

Why should it be any more shameful to catch an infection from sex than it is from shaking hands, a kiss or being coughed upon? Why is it shameful to have genital herpes, even though more people have oral herpes and everyone can see those outbreaks?

I suspect it is because shame and stigma are effective weapons of control that have been used throughout history to marginalize women, people of color and the L.G.B.T.Q.+ community. S.T.I.s are generally higher in these groups: a combination of biology, as transmission to the cervix, vagina and rectum is easiest for most S.T.I.s, and traditionally people in these groups have less access to health care because of economic marginalization or prejudice, which leads to less access to screening and treatment.

In the 1800s when an indigent person had the “pox” (either syphilis or gonorrhea; diagnostics to distinguish reliably between the two did not exist at the time), a public declaration was required for assistance from the churchwardens. Men and women with the same afflictions were sent to different places — women to a workhouse and men to a hospital.

Those with money could, of course, avoid public disclosure altogether and obtain medical care.

In many ways the public shame and stigma has remained unchanged. Economic disadvantage prevents many from screening and treatment. People wishing to protect themselves from S.T.I.s through safer sex practices — especially those who are not cis gendered white heterosexual men — can be falsely labeled promiscuous or dirty (whatever that means). Or both.

Those words can be thrown at them by their partners, their community, strangers online and even via stigmatizing interactions with health care professionals.

The consequence is that many S.T.I.s are on the rise. Between 2013 and 2017 (the last year for data) the number of cases of gonorrhea have increased by 67 percent and syphilis by 76 percent.

And while the rates of new diagnosis of H.I.V. a