PSYCHOSOCIAL ASPECTS OF STDS
BIERMAN CENTURY CITY DERMATOLOGY
Stanley M. Bierman, M.D., F.A.C.P. (C2003)
  1. MAJOR BEHAVIORAL RISK DETERMINANTS FOR STDs
    1. Promiscuous behavior
      1. Large numbers of sexual partners
      2. High rate of new partners
      3. Casual anonymous sex
        1. Bath houses. tea rooms
        2. Singles bars
      4. Presence of other STDs (GUD) "genital ulcer disease"
      5. Psychosocial considerations
        1. Macho image
        2. "Popularity"
      6. Sexual behavior by gays
        1. Mean number of lifetime partners in NYC HIV+ gays=308 with range 4 to 14,000 HIV- gays=143
        2. Mean number partners = 4.5 with 23 encounters prior 6 mos
        3. Mean number lifetime sex encounters=1,275
        4. Perceived risk of anonymous sex (1) Uninformed
          (2) Self-destructive
          (3) Gamble for sexual fulfillment
          (4) Defective impulse control
        5. Gays underestimate vulnerability
        6. MOST PEOPLE INFECTED WITH HIV HAVE NO SYMPTOMS BUT CAPABLE OF TRANSMITTING INFECTION TO OTHERS
    2. Intravenous drug and alcohol abuse
      1. Drugs.....crack cocaine
      2. Intoxicated less inhibited behavior
      3. Avoid barriers means contraception
      4. Prostitution to support habit
      5. Large numbers of partners
      6. Despite educational attempts... no change in safe sex behavior (50%)
    3. Specific sexual practices
      1. Anal receptive intercourse
      2. Anal insertive intercourse
      3. Oral sex
      4. Analingus
      5. Fisting
      6. Rectal douching
      7. Vaginal intercourse without condom
      8. Introduction foreign objects
    4. Prostitution: multiplier of STDs
      1. Reservoir of STD...high frequency transmitters
      2. Worldwide and all strata US society
      3. Condom use 39 to 74%
      4. Transmission HIV from non IVDA prostitute less likely
        1. 1/500 exposure (Nahmias) 20 transmission in 5 years (theoretical model)
        2. Prevalence 33%-88% HIV sero+ African prostitutes; 6-8% population sero+
        3. Uganda prostitute 8% transmission HIV after single coital exposure
        4. HIV+ prostitutes: Athens 6%; Mustang Ranch 0% South Florida 41%; New Jersey 57%
      5. Drugs for sex...support addiction
        1. 60% IVDA as HIV+ in NYC
        2. 20% IVDA HIV+ in Philadelphia
      6. Legal punitive interventions: victimless crime
        1. Criminalizing
        2. Penalizing clients
        3. Regulating
        4. Constructive intervention
      7. STD-based intervention
        1. Education
        2. Condoms...spermacides
    5. Contraception: inconsistent use
      1. Barrier methods of contraception
        1. Douche
        2. Diaphragms, sponges
        3. Condoms (latex)
          (1) 15% married; 9-16% unmarried
          (2) 4% breakage rate
          (3) Women 40% retail sale; up from 10%
          (4) Misconceptions about condoms
        a) Belief that use decrease pleasure
        b) Viewed as contraceptive only
        c) It is "unnatural"
        d) Underestimate personal risk of coitus
        e) Partner would be "offended"
      2. Birth control pills
        1. Decrease PID but inc. Gonorrhea
        2. 33% use; 22% married 48% unmarried
      3. IUD (Intrauterine device)
      4. Sterilization
      5. Conclusions
        1. Inconsistent pattern of safe sex practices
        2. Oral contraception favored over barrier methods
        3. Knowledge of STDs not translated into safe sex
        4. Reservoir of sub clinical infection
  2. S0CIOLOGIC AND DEMOGRAPHIC PERSPECTIVES OF HUMAN SEXUALITY

  1. Postwar social and sexual trends
    1. Population bulge from post war baby boom
    2. Younger age first marriage
    3. Rising divorce rates=50%
    4. Emerging anti-establishment views
    5. Changing moral tone c inc. non-marital coitus
    6. Trivialization of love with "sport-fucking"
    7. College and education
    8. Increased numbers women in work force
      1. 50% married/ 74% divorced women at work
      2. 1920s only 24% women worked
      3. Transition from homemaking to paid labor
    9. Women as equals in the competitive workplace
      1. Impact of women's lib
      2. Sexually experienced newly single women
      3. Growth in divorce rate
      4. Singles bars/one night stands
      5. Contraceptives and abortion rights
      6. 28% households with single parents
    1. Increased use of recreational drugs
    2. Liberalization in sexual attitudes
    3. Incr. sexual freedom with BCPs
    4. Increase in cohabitation
    5. Alternative life styles
    6. Candor in movies, TV, books
    7. Inner-city, poor, minority
      1. Working parents
      2. Limited educational opportunities
      3. Urbanization plus School delinquency
    8. Unstable political structures
    9. Conclusions
      1. Postwar "Sexual Revolution"
      2. Sweeping change in gender roles
      3. Crumbling traditional role of family
      4. Socioeconomic problems in inner city
  2. Sexual Behavior Heterosexuals
    1. Teenagers: sexual identity. peer influences
      1. Median age 1st intercourse= 16.1 years boys; 16.9 for girls
      2. 33% boys / 20% girls are sexually active before age 15.
      3. 19% c more than 4 lifetime partners
      4. 10% teenage girls get pregnant each year
      5. 10 to 56% teenagers use condoms
      6. 40% teens sexually active
      7. Higher incidence black vs. white
      8. Incidence HIV in runaways (age 11-18)
        (1) 12% San Francisco
        (2) 5.7% New York
        (3) Black and Hispanic youth = 56% AIDS
        (4) 30% engage in "survival sex"
        (5) Los Angeles 92% runaways are active
        (a) 7% initiate by age 15
        (b) condom use= 50%
      9. 1,415 cases of AIDS in 13-19 y/o
      10. AIDS is the 6th leading cause of death
      11. Lack of communication parents/teachers
      12. Sex education may be insufficient
    2. College men and women
      1. Contraceptive use: 83.3% time
      2. Ethniticity and religion not influence sexual behavior in college students
      3. 10-18% engaged anal intercourse and condom use 18.5% time
      4. Prevalence of HIV among university students is 0.2% (0.04-0.15% for students age 18-24; 0.2-2.9% for those 40 or older

  1. Single adults
    1. Virtually all adult males and 2/3 women sexually experienced
    2. College men with 6 lifetime partners; women 4.6 partners
    3. Non college men=10 lifetime; women 5.2
    4. Divorced men more active: 8 per year; women 4/yr
  2. Unmarried cohabiting couples
    1. Cohabiting due to liberalization lifestyles
    2. Less societal disapproval and economic realities
    3. Greater blacks vs. whites
    4. More sexually permissive at early age
  3. Sexual behavior General Social Survey (1481 respondents
    No sex 21.5%
    One partner 59.6%
    2-4 partners 10.6%
    5 or more 2.2%
    Unanswered 6.1%
  4. 6% men and 1.2% women said partner was "casual date"
  5. 700,000 single men age 18-29 and 100,000 single men 30-44 had 10 or more partners per year. thus at high risk STDs
  6. Conclusions on unmarried (since Kinsey's day)
    1. Earlier age sexual initiation
    2. Inc. prevalence of premarital coitus
    3. Greater adolescent sexual activity
    4. Inc. growth in cohabitation middle class
    5. Growth in divorce rate has resulted in inc. population of sexually active
    6. Growing population never married sexually active
    7. Increase in casual sex without commitment
  7. Married persons
    1. Rate of nonmonogomy varies from 20% to 50% men; 10% to 32% women
    2. Related to inc. opportunity and BCPs
    3. Majority nonmonogomous women confined to 1 partner
    4. Modal # extramarital: men= 2-5 partners
    5. Mate swapping, group sex, swinginging=1 to 3%
    6. Married-same sex contacts
  1. Conclusions on married couples:
    1. Significant minority married people engage extramarital relations
    2. Minority extramarital encounters with partners of same sex
    3. Low incidence of swingers
    4. Concern over STDs
  1. Sexual Behavior Homosexuals
    1. Incidence 5-10% population
      1. Exclusive same gender preference
      2. Occasion same-sex
    2. Relationships (Bell and Weinberg)

  1. Close-coupled: 10% stable "marriage"
  2. Open-coupled: 18% "marital"+ others
  3. Functional: 15% single+high score relation
  4. Dysfunctional: 12% above+ concerns over HS
  5. Asexual: 16%
  6. Mixed: 28%
  1. Coupled homosexuals
    1. Upwards of 50% long-term relations
    2. 80% men nonmonogomous; 28% women
    3. 43% men with greater than 25 partners
  2. Higher rate sexual activity gays vs. straight.
  3. Cruising, tearooms= sex with strangers
  4. Racial differences: blacks twice as active
  5. 40% whites and 1/3 black gay male's c more than 500 lifetime partners.
  6. Amongst HIV+ blood donors: Mean lifetime = 20 90% reported at least 25 lifetime
  7. Alcohol and drug abuse assoc. inc. risky behavior. More for adolescents than adults
  1. Majority of lesbians report fewer than 5 lifetime partners
  2. 53% lesbians had monogomous relations
  3. 2.5% gay male serconvert each year
    1. From age 20-30... 50% HIV+
    2. From Age 20-50...50% HIV+
  4. Gay behavior (20/20 TV)
    1. ? Suicide mission
    2. Symbolic commitment
    3. Reason for unsafe sex
      (1) They are in love
      (2) Physical intimacy
      (3) Absurd rationalization
      (4) Profound carelessness
    4. AIDS education..."game for life"
    5. Fear is good
  5. San Francisco gays:
    1. 20% initially altered behavior then relapsed into high risk sex
    2. 30% changed their high risk behavior and sustained behavior
    3. 48% consistently engaged in low risk sex
    4. 2% continued in high risk sex
  6. Despite education on safe-sex, nationwide survey of 5,000 HIV-negative gay men, 11% seroconverted in five years
  7. Conclusions
    1. Greater inc. sexual activity gay males
    2. Sexual behavior changing in relation to AIDS threat
    3. Lesbians with less frequent sex c fewer partners
    4. Educational efforts to inform gays of risk of STDs have not always been successful
  1. EIGHT BEHAVIOR MODIFICATIONS FOR STDs
    1. Celibacy
    2. Wait longer to have sex
    3. Monogamous relations
    4. Limit number of sexual partners
    5. Avoiding oral and anal sex
    6. Use condoms
    7. Insist on vaginal spermicides
    8. Inquire as to partner's prior sexual behavior
  2. QUESTIONS ON SAFE SEX
    1. Have you been tested for HIV or other STDs?
    2. How many sexual partners have you had?
    3. Have you ever been with a prostitute?
    4. Have you ever had sex with another man?
    5. Have you or your partners ever injected drugs?
    6. Have you ever had a blood transfusion (prior to 1985)?
  3. WHAT IS SAFE SEX?
    1. Massage
    2. Hugging
    3. Frottage (body-body rubbing)
    4. Mutual masturbation
    5. Dry kissing
  4. WHAT IS PROBABLY SAFE SEX?
    1. Anal intercourse with condom
    2. Fellatio interuptus
    3. Mouth-mouth kissing
    4. Vaginal intercourse with condom
    5. Oral-vaginal contact
  5. PSYCHOSOCIAL RESPONSES TO STD
    1. Individual's perceived response
      1. STDs are a deserved outcome of indiscriminate sexual behavior and punishment for sexual sins.
      2. STDs are a consequence of individual inadequacy that leads to sexually indiscriminate behavior.
      3. STDs are a consequence of the breakdown in traditional social values and rapid social change.
      4. STDs are solely the result of an individual coming in contact with a virulent pathogen.
  6. PSYCHOSOCIAL RESPONSES TO STD
    1. Abnormal Reaction to STDs
      1. Risk of life style
      2. Denial
      3. Anxiety and hypochondriasis
      4. Shame and guilt
      5. Venereoneuroses
        1. Perseveration and rumination
        2. Factitial (Munchhausen)
        3. Obsessional
        4. Phobic
      6. Unique aspects on AIDS
        1. Extreme because (1) Fatal
          (2) Stigmatized...gays and IVDA
          (3) Guilt and self blame
          (4) Emotional impact of isolation
        2. Disbelief and denial
        3. Depression
        4. Anxiety
        5. Endogenous complication...neuropsychiatric (1) Encephalitis. Lethargy, depression
          (2) Impotence, memory
          (3) Dementia
        6. Abandonment
        7. Financial impoverishment
        8. Death
  7. REALITIES AND MYTHS ABOUT BEHAVIOR MODIFICATION
    1. Knowledge about high risk behavior and AIDS
    2. Perception of personal risk
    3. Perceived efficacy of behavioral change
    4. Belief that science will provide a cure
    5. Demographic variables
    6. Social support networks
    7. Sexual impulse control
    8. Alcohol and recreational drug use patterns
Famous names of individuals who have died from AIDS:
Rock Hudson, Rudolf Nureyev, Arthur Ashe, Howard Ashman (Beauty-Beast and Little Mermaid), Michael Bennet (Chorus Line), Brad Davis, Robert Mapplethorpe, Liberace, Tony Perkins.
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