It has been calculated by the Center for Disease Control that there are over 15 million new cases of sexually transmitted disease (STD) reported annually and probably three times that number are treated by physicians who do not report them. The CDC estimates that 65 million people in the US are living with an incurable STD in the year 2000. How is that possible, when there is a national campaign for "Safe Sex" and every other commercial suggests using a condom? If it were only that simple. What I am going to tell you may be obvious, or it will astound you.

First, you must count every orifice or receptacle in the human body. Then you must count all the appendages of the human body, including fingers and toes, and any inanimate object that resembles them. Be creative! Then if you do all the combinations and permutations of these two numbers, you will come to over one hundred ways that you can contract or transmit an STD. Not possible you say, well read on.

As a unique community, we, who probably partake of the pleasures of orogenital sex more than most, should be aware that all of the STDs, including HIV transmission, can be transmitted this way in both directions. As we shall see, STDs run the gamut of organisms from common bacteria to viruses and many unusual organisms such as fungi, spirochetes, protozoa, and retroviruses. And equally important is the fact that if we use our fingers, toes or inanimate objects in the anogenital region and then place them in contact with any of our orifices, we can likewise transmit any of the STDs. So let me first dispense with HIV and AIDS, which comprise only .5% (one-half percent) of the STDs, as a topic for another day.

Since transmission is more likely than pregnancy in our community, let me emphasize the point. "Know your partner very well." This should include past STDs, current symptoms, i.e. urethral or vaginal discharge or burning, orogenital sores and current test results, if possible. One night stands and multiple sexual partners increase your chance of acquiring an STD. Oh well, you knew that anyway. So let me tell you what's out there waiting to inhabit your body.

First, the most common STDs are associated with an initial urethral or vaginal discharge. These include N. gonorrhea (GU), C. trachomatis (Chlamydia and NonGU), Trichomonas (T), and Monilia, a common human yeast, residing everywhere it's dark and damp. All of these can be in a carrier state, with little discharge and can reside in the mouth with the exception of T. So say "aah" please and look for white plaques on the tonsils or tongue. All can be eradicated usually with a single dose of medication. If the symptoms persist, longer treatment (Rx) of 2-4 weeks maybe necessary. Left untreated, the sequelae are scarring of the urethra which can impede urination for life and testicular or ovarian swelling and pain which can result in infertility. Serious Stuff!

Next we should concern ourselves with STDs which produce sores or ulcers on the genitals and mouth. The most prominent and not easily missed solitary ulcer is fortunately the least common, the fiery, angry "chancre" of syphilis. Recently the CDC reported an increase in syphilis cases in the SoCal area. Again prompt antibiotic Rx will eradicate the spirochetes and healing of the ulcer will quickly occur. But most common and most ubiquitous, residing in one-quarter of the U.S. population, is a virus which was first described by the Romans. Genital Human Herpes Virus, HHV-2, manifests itself by multiple small sores in a cluster on the genitalia, which may or not be painful. At this point they are very virulent and easily transmitted to any orifice or surrounding skin. They can be transmitted by any and all appendages. Remember that point! HHV-1 which has been associated with external oral "cold sores" accounts for only 10% of GHHV infections. Antibodies to HHV-2 have been detected in 20% of the US population indicating past genital infection. Presently Rx is in ointment form and capsules which shorten the duration of the sores, but does not prevent their recurrence. Rx only with the ointment is discouraged. So a daily prophylactic capsule is recommended to prevent recurrences, which are certain to recur in smaller numbers. A reservoir beneath the skin is ever present after infection and may be infective without visible sores. Aside from local scarring and discoloration at the sites, there are no known sequelae except in pregnancy with newborns and HIV infected individuals.

When visible warts are noted on and around the genitalia, we must realize that they are an STD. They are caused by the Human Papilloma Virus (HPV) of which more than 30 subtypes have been identified. Visible raised warts are benign in 90% of the cases, but flat warts on the genitalia are more likely to contain subtypes (HPV16, 18, 31 & 45) which lead to serious cervical dysplasia, a cancer precursor in women, and precancerous conditions on the penis. These are easily removed with caustic wart medicines, liquid nitrogen cryotherapy and best with a Carbon Dioxide Laser. The treatment must reach just below the skin surface and will leave some mild discoloration or scarring. But like herpes, this virus is spread by skin to skin contact and leaves a reservoir both intraurethrally and beneath normal appearing skin which cannot be eradicated.

If we accept the fact that HIV is most easily contracted through anogenital contact or the direct contact of one body fluid with another, like semen with blood, we can then understand how viral transmission can occur with any open sore or lesion within the mouth or rectum. So the last group of STDs we will discuss are the vaccine-preventable STDs, Hepatitis A (HAV) and Hepatitis B (HBV). Since both of these viruses are shed into the bowels, bloodstream and possibly find their way to the vagina during the initial illness, you are highly at risk to contract these illness, if your partner appears jaundiced (yellowish.) But the problem is that they can exist in a chronic carrier state like Hepatitis C for years following the initial infection. So we are just beginning to appreciate the reservoirs of these viruses in our population. The good news is that there are reliable vaccines for Hepatitis A and Hepatitis B. If you know that your partner is a carrier, or you have frequent anogenital contact, you are advised to obtain these vaccines prophylactically. While all of these viruses including HIV have been detected in the saliva in small numbers, there is no evidence that saliva by itself is involved in transmission.

I have purposefully not included the names of medicines which can eliminate these STDs, because quick medical treatment is necessary. This is not a "do it yourself" course, because I do not know any over the counter medicines that will eradicate the above STDs. So what you have is a primer for awareness and prophylaxsis (called a condom.) Be vigilant, and see your doctor promptly for any of the described symptoms.

Best Wishes for your New Future.
Cerise Richards, MD