Keywords: Sexually Transmitted Illnes; sexuality; STI stigma

DOI: http://dx.doi.org/10.3126/njdvl.v8i1.5711

Nepal Journal of Dermatology, Venereology & Leprology 8(1) 2009 6-

DB Pokhrel

Nepal Journal of Dermatology Venereology & Leprology

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Sexually. Transmitted Infections, Sexuality and STI Stigma among Nepalese youth and adults Pokhre1 D.B Professor & Head, Department of Dermatology & Venereology Institute of Medicine, Maharajgunj Campus, TV Teaching Hospital, Kathmandu, N epa!. ~ji~~~g~Sp~i~~~'s~~P ····:[~~/"~~~~~lerps~Q4gf~S2~al~~1~&GJllts;...... . 'Xf'~tli~'~l1~ .• ad,~~~s?fa,&~s.· •. ·.f~.;.~~ ·~;t,~~~¥~itJ;&.:}¥~tll:~lie:·sexu~1·p~Q~I~tn;s:,:·m91U?i11~·.tl1~t.:q~ :~ex~ally .•. :tJ;~n~~itre?illp-~s~~:s;.·~a;s;:.ci.~~ .;:~11~;9~1·~~~,~r~r~lellc~. ".?,·~ ..• s~~f~1'~·:.S,t~~rp,~:·~¥t~~atiqllt?:~ll~ir ~.~f~~l~·~h~:,iQ~ ..•. ~~q.·.~1F~~.. . Y'~~t~d,.~~~t::()¥~M::4~;§om·.~~· ... ··qh:~.,.··:o~.· •• :tlI·,.·,· ·····:~lJ~:.ijurill&ti:~9tlIe . Q;t';t~~ir{~Y:~\tlati911}jtlt.~ •• 8," ' ~~·~.~%Y.'pf~~.. rt.··~~tf. •............. ' ,a;l~·:..S:i~~4;~~tl.}~~(we~e. ~~f~&s,~:lf J~ti:~~ti~~:d,().~i.·, .... ; .•.. "'::;:~~':' ..•. :.. <.: •... : .. ::::::: •.• r:~: ... : .. , .. , .. · .. ·.~~~~~g;~]j);i'::~t •. ·: . ·,g::tli.e~ti1?~ti~e. AlA1psr.~~o/c>. ,.~.~;.;·tp.~·s1:U:?Y:Pf'::: .~~· •• ~~~·~~~ ... : .. ,~~t~~~~~~f.~~~#~~.~~lfltiql1.; •• ,:. : ............. ,'; .. :.,; .. , .. : .... ::·Q~~l3J:~fu19~t ~.9~,()~~lle~~e~¢.f(:)1JD?::tQ .•. · . ··,:g:qQngQ1Jl1S .•.. at·~Q1Jl1.e:,p.qint .· •. C?f~i~~, .QD~y·8,%~,weJ;e.·f:Q'micltQ.1f~Vy :a:s~~~ifiP:~~~¥1J:: ::.~r?f~~~:£~ .'", .'. ..'a~~p.~:~{~l·.~1;lq'~llal·:s,~;~,:;;':: . ,::: :;'<.:; ...• ::: .... ::. '.:' .:.: .... K(3¥.'r"~rg$::,S~~1J~~lyTt;~~~l;Uj~ty4:;~1;;¥~~~, :s~~~~lity:~Dd$r!Stigma . . . Introduction Globally Sexually Transmitted infections are among the most common public health problems with their prevalence ranging widely (From less than 1 % to up to 40 % among the reproductive age group population of different communities. It is estimated that every year more than 340 million new cases of curable STIs occur globally l,2 and it is also estimated that 1 in 4 Americans have STIs3 at any point of time. STIs in Nepal have also been considered as a major group of diseases causing significant morbidity amo.ng some targeted group of population including the youths. It is been dealt along with HIV by a separate wing of the Department of health from the ministry of health and population of Government of Nepal, called NeASC (National center for AIDS and STD control) in close coordination with many other national and international non governmental organizations. The true prevalence ofSTI in Nepal is not known but small scale studies carried out in different groups of population have reported STIs to be one of the major public health problem4 of the country. The sufferings from S TIs are reported from the ancient time with different descriptions, which shows that the illnesses are as old as the humankind. However, STIs had not been able to grasp the significant importance among public health, till its relationship with HIV infection has been strongly established.5'6'7 Today,STIs stand together with HIV infection as the major public health issue and billions of dollars are being spent globally to find the ways on how to provide efficient treatment and how to avoid STIs. The success of such efficient STI management program in the long run, is expected to significantly reduce HIV transmission as evidenced by the reports of Rakai, Masaka and Mwanza study from 199~-1998.7 Most of the STI management programs gi!ve major focus to diagnose treat and prevent STIs, but almost negligible attention is given to cover up the psychological aspects of the disease~ Stigma, which is defined as 'the negative judgment and prejudice towards those who are infected and affected' , is very high among STI population. STIs being considered as a social taboo in the society, persons infected to it are not socio-cult:urally accepted. Still a high degree of discriminations (defined as 'unequal treatment to those who are known as infected or affected') prevail to those who have any S TIs, even by the health care providers. The fear of discrimination further increases the tendency to hide the disease and thus promotes the disease progression and thereby causing unlimited burden of self-stigmatization on STIs. As a consequence of a high level of stigma and fear of discrimination on STIs within the society, in one hand it leads to the tendency to hide the infection at the individual level, which further helps to increase the morbidity caused by the disease progression and their sequele as well as promoting its transmission to others. And in other hand, it further causes significant anxiety or depression to the affected individual even when the individual is completely cured of the infection or there is no such infection 'at all, ultimately increasing the sufferings of the individual and his/her family to a greater extent. Objectives of the study 1. To identify the prevalence of self stigma among youths and adults. . 2. To find out the true prevalence of STls among those youths and adults having STI related symptoms. 3. To study the pattern of sexual behavior and sexuality among them. 4. To find out the common mode of sexual act among them. Methodology Type of study: Duration: 2007) Prospective study 5 year (July 2002- June Study: "Sexuality, SexualLy Transmitted Infections and STI Stigma among Nepalese Youths and adults" Place: Department of Dermato-Venereology of TUTH and private clinic Method of information collection: Defined Format of proforma on: Demographic data, sexual history, ~ymptoms, clinical fmdings, laboratory fmdings and. diagnosis along with the individual's self evaluation status on STls Results Out of 1852 male adolescents, youths and adults with genital complaints only 28% had true STls and the rest 72% were either already cured or had no STls at all, but were having strong self stigma of STls. The majority of the study population belonged to youth and young adults and slightly more than half were married (Table 1). Table 1. Age wise distribution and Marital status of the study POlJUlation Age Married Unmarried Total 15-25 163 655 818 26-35 710 212 922 36-45 86 26 112 Total 959 893 1852 Out of the total study population, only 27.6% of them were found to have one or more STls during the time of the study and the rest (72.4%) although strongly believed that they have one form or other of STls, were not having any STls in reference to the clinical and available laboratory tests (Table 2, Fig.1). Table 2. Diagnosed STIs (n = 511) among the total patients with genital symptoms (n = 1852) S~No Diagnosed STI Number of Patients Percentage 1. Non Gonococcal Uretlnitis* 218 11.8 2. Gonococcal Uretluitis 57 3.0 3. Herpes Genitalis** S4 2.9 4. Genital Wmis** 78 4.2 S. Syphilis 109 5.9 6. Otllers: *** 48 2.6 7. Total number of STI patients 511**** 27.6 * Diagnosed on the basis of finding on Gram Stain on urethral swab (No GNID but =5 PMNL/HPF) * * Diagnosed on the basis of clinical findings * * * 34 had Pearly Penile Papule, 7 Seb. keratosis, 5 Para urethral Cysts, 2 Bowens disease and 1 SCC **** 44 patients had more than one STI (35 had two STIs and 9 had 3 STIs) and 14 were also PLHA 12 10 8 6 4 2 o Cl Non Gonococcal Urethritis • Gonococcal Urethritis III Herpes Genitalis o Genital Warts • Syphilis m10thers Fig.l. Percentage distribution of various STls. The major presenting symptoms of the study population were found to be as follows (Table 3). Burning or prickling pain, itching, sore or superficial erosion, discharge, premature ejaculation and decreased sexual desire or erectile dysfunctions etc. were among the commonest. Table 3. Presenting symptoms related to genital problem I?iscl1arg~.perllretllra!geIlit~lia 5: .. R~~il~;~ i~~'~I~ ~{i~~:~;~ti;~ g~it~ii~ ... 6.' Fleshy grmvth in & around geIlitalia 177 9.6 .!J_ ... !:'~~!~a.!t!!~~§ja.~I!!a.!!.~!~.. .. _... .. 8 i . .)?~~!:ea~t:.~~~l~ual ~~~i!:~ .. J()5, 16.8 ........ J,3:t.:~~~i!t:. .. ~.y"~~\!!!~!i~~~... .... ............... .... . . .... . ... ..[ 312 ... .. ..1 ....... . 10't-! --::;D~ec_re-.ase=d_siz_ei-:-fdi_sto_lt.--ed-'"'geI_lI-;·ta:-lia--:-7_=----+: ----.:1::.:..5.:..-6 _-+-__ 8.4 ' Others. (pigmeIltOlY changes, Scrotal :;welling, i 11 dyspalUuia etc) , 125 6.8 Note: Nearly eighty percent (78.3%, n= 1450) had more than one presenting symptoms) II Almost 2/3rd of the study population (63.5%) gave history of having only vaginal sex, about 14% were having vaginal, anal and oral sex and almost 18% were having vaginal and oral sex. A small number « 5%) however did not have any heterosexual contact. (Table 4, Fig.2). Table 4. Mode of sexual act: * Others include: Mutual masturbation, rubbing/pressing the genitalia against the different parts of body surface etc ** Self masturbation, use of sex toys Vaginal III Vaginal + Anal+oral o Vaginal + Oral .MSM l1li Others' Fig.2. Percentage distribution of modes of sexual contact of patients. 58% of the study population had more than one partner. 27.8% had single extramarital sexual partner and almost two percent had no sexual contact Table 5. Sexual Partners N umber of sexual P.artners More than one partner 1076 Single partner other than spouse 515 Relation only with spouse 224 Never had any contact 37 Total 60.00% 50.00% 4000% 30.00% 20.00% 10.00% 0.00% Total Percentage (58.09%) (27.80%) (12.09%) (1.99%) 1852 (100%) More than one Single partner Relation only Never had any partner other than with spouse contact spouse Fig.3. Sexual contact history of patients. Note: Out of the total 1591 who gave history of extramarital contact, 107 (5.8%) gave history of single sexual contact. Although, 49.2% of those having extramarital sex were found to have used condoms, only 7.8 % were using it consistently with all of their sexual partners. 55 out of782 (7%) of those using condom replie~ that the condom was broken in one or more occaSIons. Table 6. Condom Use within extramarital sexual contact (n= 1591) Sexual Partners Casual Condom use Multiple partner 456 (42.4%) Single partner other than wife 202 (39.2%) Consistent Condom Use 102 (9.5%) 22 (10.9%) Total 658 (41.4%) 124 (7.8%) Discussion Although, STI is one of the common causes of morbidity, fear of having STI with or without any risky behavior is becoming far more common among the youths ofN epal. This study has revealed that almost two thirds of the persons who presume to have STIs are not found to have any STIs even in repeated laboratory screening. Moreover, they are found ·to be suffering from some kind of depression or anxiety disorders reflected in the different forms of their abnormal symptoms and sexuality. Similar study carried out among 500 such population8 in 2004 has also revealed similar data. A small study done by Frank E et. a19, among the normal couple on their sexual function had revealed that 40 % of men and 63 % of women had some form of sexual impairment. Similarly, several studies have proved that, illitenicy with lack of sex education leads to the' sexual dissatisfaction because many of them· can not differentiate between what is normal and what is abnormal sex behavior. Since even those persons who confess that, they had never had any sexual contact with other partners, think that they are suffering from some S TIs which have resulted in different manifestations. 8 In this context, the present study clearly indicates the role of adequate sex education among the youths and the need of proper STI Counseling and psychotherapy to the sufferers. Conclusion The study, one of the first of this kind in Nepal, revealed that a significant number (>72%) of male youths and adults suffering from some form of genital symptoms were on self stigma of having STIs, although they had none. Although almost 86% were having extramarital sexual relationships, only about 49% were found to be using condoms at some point of time and more over, only 8% were found to have used it consistently. More than 95% of them were having heterosexual contact. 63.5% were found to have only vaginal intercourse; however the rest 36.5% were also having oral and anal sex. The study also reveals that, the lack of knowledge regarding sexual drive, sexuality and reproductive health among the youths and adults make this group vulnerable to different mode of sexual activities. Because of their indulgence in those activities, which normally is not accepted by their society and their culture, leads them to self-stigmatize on STIs and manifest with bizarre symptoms. Moreover, these groups of youths are mostly found to have anxiety or depression due to deeply rooted stigma onSTIs and so are need of proper education and awareness on STI and sexuality along with counseling on STI management and psychotherapeutic support. References: 1. World health Organization. Global Prevalence and incidence of selected curable Sexually Transmitted Infections: Overview and estimates. WHO Geneva, 2001 2. The tools of STDs population reports, issues in world health Series 1993, No.9, Page 3-5 3. Women and teens STD crises, 2004. 4. Reports of MOHINCASCIFHI Nepal, 2005 5. World Health Organization. WHO working group on global HIV/AIDS/STI Surveillance. Guidelines for sexually transmitted infections surveillance. WHOIUNAIDS, Geneva, 1999 6. European STD guidelines, International Union against S TI and the European office of the WHO, vol. 12, Sup 3, 2001 7. Tutorials on Sexually Transmitted Infections, Topics in International Health, STI and HIV, Trustee of the Welcome trust, 2003 8. Pokhrel, D.B. "Self Stigma and Psycho Sexual Disorders a common problem of Nepalese youths of Nepal" Souvenier of the first International Conference of Dermatology in Nepal, ICD-2004. 9. Frank E, et al. Frequency of sexual Dysfunction in normal couples. N Engl J Med 1978; 299: 111-115 -

Sexually. Transmitted Infections, Sexuality and STI Stigma among Nepalese youth and adults

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Sexually. Transmitted Infections, Sexuality and STI Stigma among Nepalese youth and adults

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