Sexually transmitted diseases (STDs), also known as sexually transmitted infections (STIs), are infections spread primarily through sexual contact. More than 65 million people in the United States are currently infected with an incurable sexually transmitted disease such as genital herpes, and each year an additional 19 million people develop new cases of one or more of the 25 diseases categorized as STDs. More than half of all these new infections will affect young people ages 15-22.
A New Paradigm for Assessing STD Risk
Most personal health STD prevention programs focus largely on individual behavior as the basis for risk reduction. Many of these programs emphasize safer sex or abstinence from sexual intercourse as their preferred preventive approach. Public health STD prevention programs typically emphasize community health interventions such as free and confidential testing and treatment centers, needle exchange programs, and sociomarketing campaigns to promote condom distribution and family planning services. While both approaches have merit, each falls short of offering a comprehensive analysis of STD risks.
A more effective way to view STD risk is to conceptualize it as pyramidal in nature. A pyramid of risk model describes the interaction between personal and community risks and has four levels of risk factors: demographic, sexual/medical history, sexual lifestyle, and sexual behavior. Each level builds upon and is interpreted on the basis of risks associated with the previous one.
Level 1 Risks: Demographic Variables
Seven major demographic variables form the base of the pyramid and contribute to STD risk: age, gender, sexual orientation, injectable drug use (IDU), geography, socioeconomic status (SES), and race/ethnicity.
There are more cases of STDs distributed throughout the 15- to 25-year-old age group than in any other. Because more cases exist in this age group, the risk of acquiring an infection is greater for someone in this group or who has sex with persons from this age category. Sexually active teenagers have the highest rates of infection of most STDs. For example, teenage girls have the highest risk of becoming infected with gonorrhea. Rates for females in the 15- to 19-year-old age groups are 610.9 cases per 100,000 people. This is more than 5 times the national rate of 113.5 per 100,000. Young women in this age group are approximately 20 times more likely to be infected with gonorrhea than females 30 years of age and older. Young men have a similarly high risk compared to older men.
The risk of acquiring an STD varies by gender. Gender risks are related to the genetic, anatomical, and physiological differences between men and women. Women face a greater risk than men for both acquiring a sexually transmitted disease and developing complications for several reasons. Heterosexual women are receptive sexually—vaginally, orally, and anally. This greatly increases their risks for initial infection by exposing a greater surface area of mucosal tissue. Once infected with most STDs, heterosexual women tend to be asymptomatic more often than heterosexual men. Most heterosexual men notice initial symptoms of infection, whereas about half of women are asymptomatic. Because of the asymptomatic nature of most STDs in women, more women than men do not seek treatment during the initial stages of infection. This delayed access to treatment results in progression of the disease and a greater likelihood of developing complications. About 15 percent of women develop complications associated with gonorrhea or chlamydia, compared to less than 1 percent of men.
STD risks vary by sexual orientation. Gay and bisexual men, like heterosexual women, are receptive sexually and tend to have asymptomatic infections. In addition, certain diseases, such as HIV and hepatitis B, exist in endemic levels in the gay community and are incurable. Heterosexual men are at lower risk than heterosexual women and gay men because they are not receptive sexually, and female-to-male transmission of STDs is less efficient than male-to-female and male-to-male. Additionally, vaginal fluids are less likely to transmit infection than is contaminated semen. Lesbian women have the lowest rates of STD infection. Gay women tend to have fewer sexual partners over the course of their lifetimes, and they do not engage in vaginal or anal intercourse involving ejaculation.
STD risk is strongly associated with the number of injector drug users (IDUs) in a community. Injector drug use impairs users’ ability to make good decisions regarding sexual behavior and often involves needle sharing between users. This facilitates the transmission of blood-borne infections such as HIV and hepatitis B. A vicious cycle of drug abuse, exchanging sex for money or other resources, unsafe sex, and infection with a variety of STDs has occurred since the mid-1980s and has led to the resurgence of syphilis in urban America.
STDs are not distributed evenly across America. They are disproportionately higher in urban areas than in rural or suburban locations. STDs seem to be much more common in pockets of urban populations called “core groups.” Infected core groups are a major contributing factor for higher STD rates in urban communities despite individual behavior. For example, the risk of transmission of STDs among core group members and their sex partners is 300 to 600 times greater than among the U.S. population in general.
Level 2 Risks: Sexual and Medical History
A person’s sexual and medical history greatly influences the partner’s present level of risk for acquiring STDs. The number of different sexual partners a person has had over the course of a lifetime correlates to that person’s current STD risk. In general, the greater the number of lifetime sexual partners a person has had, the greater the risk that individual poses for a current sex partner. One’s contraceptive history also influences the present STD risk. Barrier contraceptive users have the lowest rates of infection. They are followed by other contraceptive users and nonusers, who have the highest risk. Persons with a history of IDU have an increased incidence of infection with blood-borne diseases, particularly HIV and hepatitis B. Last, persons who have been infected with STDs in the past are more likely to become infected again than those who have never been infected.
Level 3 Risks: Sexual Relationships
There are two dimensions of relationship risk: familiarity risk and exclusivity risk. STD risks decrease as sexual relationships move away from multiple, anonymous, sexual encounters toward monogamous (with uninfected partner) partnerships. Familiarity risk is synonymous with anonymity risk. Studies show that the less familiar individuals are with their sex partners (the greater the anonymity), the greater the risk. Anonymity influences one’s ability to make informed choices about the STD risks posed by potential sex partners. Exclusivity is associated with monogamy and must be examined in both partners to measure it accurately. If one partner is monogamous but the other is not, the benefits of exclusivity are lost. Exclusivity only works when both partners are uninfected. Exclusivity can actually increase STD if one partner is infected. The highest-risk sexual lifestyle is one that is nonexclusive and anonymous.
Level 4 Risks: Sexual Behavior
In general, behaviors that incorporate unprotected penile insertion and ejaculation entail the most risk. The lowest risk behaviors are nonpenetrative and do not include ejaculation and the exchange of bodily fluids. Penetration of unlubricated tissue, such as that in the rectum, allows direct access of infectious agents to the bloodstream. Theoretically, STD risk is always greater for the receptive partners of any sexual activity, since they receive the contents of the ejaculate.
Implications for Risk Reduction
The pyramid of risk model shows that STD risk is multifaceted in nature and combines a person’s current personal sexual behavior and lifestyle with past sexual history and demographic factors. Such a model demonstrates the futility of focusing prevention activities exclusively on current personal behavior while ignoring historical and community risks. Though individual personal behavior is crucial to the success of prevention activities, other factors affect personal risk despite the consistent and correct use of safer sex procedures. As mentioned previously, in certain core areas, individuals are 300-600 times more likely to become infected with an STD than their contemporaries living elsewhere. In such areas, engaging in any sexual activity carries a higher risk of becoming infected than engaging in more risky personal behavior in areas with less community risk. To be effective, prevention programs must take all four levels of risk factors into account when planning interventions.
- American Social Health Association. 2005. State of the Nation: Challenges Facing STD Prevention among Youth: Research, Reviews, and Recommendations. Triangle Park, NC: American Social Health Association.
- Bearman, Peter S., James Moody, and Katherine Stoval. 2004. “Chains of Affection: The Study of Adolescent Romantic and Sexual Networks.” American Journal of Sociology 110(July):44-91.
- Centers for Disease Control and Prevention. 2007. Sexually Transmitted Disease Surveillance Report: 2006. Atlanta, GA: U.S. Department of Health and Human Services.
- Gallet, Craig A. 2002. “A Note on the Determinants of Sexually Transmitted Disease Rates.” Social Science Journal 39:613-16.
- Santelli, John S., Richard Lowry, and Nancy D. Brener. 2000. “The Association of Sexual Behaviors with Socioeconomic Status, Family Structure, and Race/Ethnicity among U.S. Adolescents.” American Journal of Public Health 90(October):1582-88.
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