Thursday, March 14, 2013

A Fresh Look at the Spread of STDs: How About.Com's STD Writer, Elizabeth Boskey,Ph.D Views the Current State of Online Sexual Health's Guide to Sexually Transmitted Diseases, Elizabeth Boskey, Ph.D  first started working in sexual health as peer health educator with the AIDS Education Group at her college, where she loved not just writing about HIV and performing sketches but talking to her fellow students about safe sex. She is now a researcher, and a Health Educator with over 20 years of experience, who recently had a lengthy, and honestly entertaining, conversation with  about the current state of online sexual health.

Let me just say, she kept it real.

What trends have you noticed in STI/STDs and getting tested from working in the field of Sexual Health?

People have been uncomfortable talking about STI/STDs for a long time, and it isn't getting better. Since I left high school, it seems like there's been a trend towards  less education in sexuality, rather than more. People seem less invested in playing “safe”. Maybe it's just that I'm working with different populations now, but they also seem to be less informed about even the most basic aspects of reproduction and disease transmission. It makes me wish we had solid, national sex education standards in our schools.

However, the world has also changed in the years since I left high school. When I was coming of age, a driving factor in getting tested and staying protected was the fear of HIV, but today HIV is much less frightening. HIV is now understood to be treatable, if you have the money and resources to pay for treatment. It's no longer seen as a death sentence. HIV as a chronic illness just isn't something people worry about the way they did before the age of combination antiretroviral therapy. ” While losing that fear has helped to deal with the stigma of HIV positivity, it has also cost a lot of people their motivation to protect themselves.

There are also social structures in place that make testing difficult for some of the groups who need it most. For example, a student at Boston University, where I am currently teaching, recently told me that there is no access to STI/STD testing on campus. Student health will happily provide a list of off-campus testing sites, but it isn't part of the student health plan.

Well, which STI/STD would you say most are concerned about now?

From a practical perspective, my biggest concern is antibiotic resistant gonorrhea. I think there's a real change that this formerly treatable disease will become untreatable in my lifetime. If it does, it's suddenly going to become a very big deal. From a social perspective, however, I'm most worried about genital herpes. It's so stigmatized that people become devastated by it to an extent that is completely disproportionate to the, usually pretty mild, symptoms. People talk about suicide, or their life being over, and that's so not necessary.

Unfortunately, herpes is widely misunderstood by not just everyday people but doctors. People don't realize how common it is, and how large a fraction of the population has no idea that they're infected – because it often doesn't cause any noticeable symptoms. There's a widespread  myth that you can only give someone gential herpes when you have symptoms. It's not true, even though many doctors believe it. This leads to lots of blame where someone who has just been diagnosed assumes their partner lied to them about risk... when the truth is that their partner might have had no idea they were infected. Additionally, and this is a big one, most people have no idea that cold sores can spread to the genitals, causing genital herpes. People think oral sex is safe sex, and because we rarely talk about “cold sores” as “oral herpes”,it's rare that someone bothers to disclose that risk..

The level of shame and fear around herpes is really disturbing, but I think that part of the reason that it's so stigmatized and so scary is that it feels unavoidable.  It doesn't seem like there's anything to do to protect yourself and your partners. People have more of feeling of control and protection when their partner has HIV. You can easily, and completely, protect yourself from HIV. With herpes, it is far more difficult – although both condoms and suppressive therapy can be used to reduce transmission.

What are some of the trends you see answering users STI/STD questions on

II think the biggest trend that I see is that men tend to email me their questions, but women post more stories.

Most of the questions I receive reflect the fact that there is still  a lot of shame in contracting an STI/STD. Many people would rather reach out to someone online if they think it can help them avoid going to the doctor. Going to an STI/STD clinic is scary, particularly in a small town where you're worried about getting seen, and going to a doctor can be even worse if it's someone you've known for a while. There are all these worries about judgment.  Contacting me online seems easier for them, even if a lot of the time all I can do is give them general information about diseases and tell them that they really need to visit a doctor – or find another way to get testing and treatment.  
What are you thoughts about In-Home STI/STD testing? 

I have somewhat mixed feelings about in-home testing. I think that, while the FDA approved in-home HIV test is a better option than not getting tested, it's far from perfect. One of my biggest worries is about potential problems with follow-up. If you get tested for HIV in a doctor's office or clinic, there is on-site counseling and a direct path to treatment. If you get tested at home, however, finding further help is on your shoulders. There's a hotline available through the company that makes the OraQuick test, but you have to be willing and ready to call it.

My other big concern is that the only thing you can test for at home is HIV. It's not the only STI/STD out there, and it may not be most people's biggest concern. However, that said, if in home testing means that people get tested more frequently, I'm all for it. It's just not a magical solution for improving sexual health. It's also not necessarily the most affordable solution, but that's another issue entirely

What about STI/STD testing in a doctor’s office?

Ideally, everyone would get tested by their doctor, and it wouldn't be that big a deal. Unfortunately, because doctors are just as uncomfortable talking about sex as their patients, it's not as easy as it could be. Doctors often fail to ask their patients if they want to be tested, and patients don't know that they should ask -- or 

what to ask for. Furthermore, many doctors don't even know what tests are available, and if they do they sometimes only test the patients they perceive as "high-risk" when the truth is that everyone sexually active is at risk of STI/STDs. That's true even for people who are in a monogamous marriage, unless they were both tested before they got together.

I will say that, for people in a big city, often the best place to get tested is your local LGBT health center. Clinics focusing on the queer community are generally non-judgmental and often have low-cost, easily-accessed testing services that aren't restricted to LGBT individuals. However, for someone who isn't part of the community, it's often a bit scary to consider walking through that door.

In your idea world, how would the culture of 
STI/STD testing be changed?

In an ideal world, we'd normalize testing. If the default was that everyone got tested on a regular basis, it would be less stigmatized. It wouldn't be such a big deal. However, that's a pretty big change. I'd settle for just convincing more MDs to discuss 
STI/STD testing with ALL of their patients, to shift the burden of asking to someone who shouldn't find it quite as stressful. The fact that doctors often try to profile their patients' risk and target testing, without even talking to patients about their sexual health, just drives me crazy!

Any other final thoughts about sexual health?

One thing that I think we really need to work on as getting past the idea of condoms as something that you eventually "get past" in a relationship. Using a barrier for sexual activity says nothing about your level of intimacy, you don't suddenly become a closer couple because you've thrown away the latex. However, right now, condoms and other barriers are often seen as an intimacy test instead of things that are just a normal part of sex. That makes using them, or stopping using them, a lot more meaningful than it has to be. People can have insanely hot sex with condoms. They can even make sex better.

On that note, one thing that I wish we told couples is that different brands of condoms can feel quite different during sex. Finding condoms and lube you that work for you can make an enormous difference in how enjoyable your sex life is. So, experiment! Get a variety pack from a condom store online, and see which one is most enjoyable. Make latex part of your foreplay instead of an interruption. Don't see safe sex as a burden. See it as an opportunity to add spice and variety to your sex life and make things more interesting.


  1. Dear Madam,

    You are right that the requirements of specific information on how to submit BTS is higher in the online environment, men are asked when it comes to their health, and protection against STDs Since we will say that the organization they manage programs dealing with health among young adults, especially people living with HIV.
    But you left out a case study on ethnic groups, drug users and people who do prostitution in Romania magnitude in the last two years has been driven by the increasing number of people living with HIV among injecting drug users especially those ethnobotanical.
    I would be delighted to take possession of your programs that implement them, and exchange of experience.

    Cristian Rosu

  2. Cristian,

    You are very right in the sense that there is a multitude of factors the play into STDS/HIV! Drug use definitely has an impact on how safe you are when you do engage in sexual activity when on a drug and of course how clean the needles are when you are using. Are there any needle exchange programs in Romania or are you familiar with the concept? Basically its the idea if you are going to use, then at least be provided with clean needles. It has had a positive impact on HIV spread in drug injection in the states.In regards to prostitution, it would be interesting to see why in particular in the last two years and furthermore, how or what existing types of support/resources (I imagine very little) for helping the community to even get tested or know that they should.

    Thanks for your thoughts as you bring up a very good point! If you have any specific questions please feel free to email me:


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