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**CONCLUSIONS**

Working with PWD concerning issues of sexuality can be challenging given the unique culture of disability. It involves a comprehensive assessment process that goes beyond identifying biomedical symptoms and dysfunction and includes key areas of concern for PWD and cultural contributions. It culminates in a treatment process that integrates evidence-based CBT and TWCBT with a sex-positive and disability-affirmative approach. Continuing education (self-directed reading, workshops, and consultation) and a willingness to challenge dominant, ableist assumptions are important aspects to working effectively with PWD.

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The number of authors was limited to three by editorial guidelines. However, the following individuals contributed significantly to this chapter: Colleen Clemency Cordes, Sarah S. Fraley, Linda R. Baggett, Kimberly Smith, and Vincenzo G. Roma.

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**CHAPTER 22**

Suppose They Gave an Epidemic and Sex

Therapy Didnt Attend?

Sexually Transmitted Infection Concerns in the Sex

Therapy Context

William A. Fisher and Stephen Holzapfel

**I** n this chapter we are reminded that sexual behavior may take place in the context of the risk of contracting or actually having a sexually transmitted infection (STI). STIs may play an important role in the etiology and maintenance of sexual and relationship dysfunction, such as in cases in which an infidelity is revealed through the acquisition or transmission of an STI. Fear of acquiring or transmitting an STI, as well as shame, blame, and guilt, may complicate sexual pleasure and contribute to problems with sexual performance. Fisher and Holzapfel argue that in order to provide competent care, sex therapists should have not only knowledge of the sexual and relationship consequences of an STI but also a foundation of knowledge regarding STI prevalence, prevention, testing, and treatment. Included in this chapter, therefore, is a primer of common STIs. Fisher and Holzapfel observe that sex therapists are generally skilled at coaching clients on how to communicate about sensitive sexual and relationship issues and about how to integrate novel sexual practices in order to improve sexual satisfaction.

The authors note that these skills may be similarly employed to coach clients about how to communicate about, negotiate, and integrate safer sexual practices in their ongoing or new sexual relationships.

**William A. Fisher, PhD,** is Distinguished Professor in the Department of Psychology and the Department of Obstetrics and Gynaecology at the University of Western Ontario in London, Ontario, Canada. Professor Fishers work focuses broadly on sexual and reproductive health behavior change, and he has published more than 200

papers in this area. Professor Fisher serves on the editorial boards of five academic journals, is a Fellow the Society for the Scientific Study of Sexuality and the Canadian Academy of Health Sciences, and has been a National Health Scientist (AIDS) for Health Canada. His research on HIV/AIDS prevention has been supported by the U.S.

National Institute of Mental Health for the past two and a half decades.

**Stephen Holzapfel, MD,** is Director of the Sexual Medicine Counseling Unit in the Family Practice Health Centre at Womens College Hospital in Toronto, Ontario, Canada. Dr. Holzapfel is an academic Family Physician and registered Sex Therapist and Supervisor member of BESTCO (Board of Examiners in Sex Therapy and Counseling of Ontario) and Associate Professor in the Department of Family and Community Medicine and the Department of Obstetrics and Gynaecology at the University of Toronto.

Dear Dr. Fisher,

Im using this e-mail for now instead of my usual e-mail to try to keep this anonymous. I feel a little more comfortable writing you from my ancient e-mail.

I was recently diagnosed with genital herpes HSV-1. I have a lot of questions and have tried researching them but have not been able to get many answers. Im hoping you may know some of these answers or know someone I may be able to ask.

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I was diagnosed in June. Im not sure who I contracted it from. I have told my boyfriend and being a great guy he stood by me through everything and has decided to remain with me. According to the doctors it is most likely I got it from him even though he has never had symptoms.

Going forward he and I are using condoms to prevent the risk of transmission.

We are not ruling out the chance that he is infected as well and also not putting him at risk for infection in case he isnt.

1\. Previously my partner and I enjoyed oral sex. We havent done it at all since the diagnosis and its a constant reminder to me that I am infected.

2\. The doctors had briefly mentioned to me suppressive therapy but scared me

out of considering it. They basically said if I use it Im going to suffer liver failure. My sex life hasnt been nearly the same since this happened and it has really upset me. Any way to try to reduce the risk of transmission and return

things to how they were before would be a bonus.

3\. Eventually someday Id like to have children. I realise that I can have kids if Im pregnant just that Id have a C-section if I had an outbreak during delivery. BUT what about getting pregnant in the first place? Because Im doomed to using a condom for the rest of my life how am I supposed to get

pregnant? With a turkey baster?

4\. It would be EXTREMELY helpful to know if my boyfriend does or does not

have the virus and if he does already have the antibodies in his system does

this mean that he is less likely to become infected by me? Every time weve asked to get tested doctors have denied us. If he is negative then we know for sure we need to be 100% careful.

Before I got diagnosed I thought I was being careful and I was definitely uninformed about herpes even though I assumed I was educated about STDs. . . . I was very careful about sex and have only had 2 sexual partners in my history, one of several years that I had tested before I agreed to do anything with, and the other we were committed to each other before we agreed to any sexual activity. My partners had only had one or two other sexual partners themselves. I sort of always assumed more promiscuous girls were more likely to get it or guys with lots of sexual partners. I didnt know that herpes can lie dormant for many years. I didnt know that STD tests dont test for herpes and I didnt know that a condom is not effective in preventing the spread of herpes.

—ANONYMOUS (personal communication, 2011)

Sex therapists are in the business of restoring sexual function and enabling sexual behavior. Sexual behavior, however, may take place in the context of the risk of contracting a sexually transmitted infection (STI), the subjective fear of contracting an STI, the acute acquisition of an STI, or the chronic carriage of an STI, each of which may result in a cascade of negative effects on an individuals sexual and relationship health.

Sex therapists must acquire a foundation of knowledge concerning STI prevention, 436

prevalence, natural history, testing, treatment, and sexual and medical sequelae in order to be able to provide competent care in relevant situations, but this has not been the traditional standard of training or care in sex therapy. This chapter reviews situations in which STIs may play an important role in the etiology and maintenance of sexual and relationship dysfunction, reviews relevant medical, psychological, and relationship impacts of STIs, and outlines general counseling principles that may prove useful in working with clients who have STI-related sexual and relationship concerns.

**THE WORRIED WELL**

Case Illustrations

"I just got back from vacation. I need to get tested for all the STIs. Now."

A middle-aged gay male who has recently "come out" and left a heterosexual marriage consults a sex therapist about his erectile dysfunction (ED). It emerges that he is very fearful of contracting HIV. His fear of infection has interfered with efforts to treat his ED with traditional sex therapy techniques and has contributed to his rejection of the therapists suggestion that he try PDE5 inhibitor treatment.

Sex therapists will often be dealing with the "worried well," whose sexual and relationship functioning is adversely affected by clinically evident or background concerns about STI risk. Accordingly, sex therapists should be able to knowledgeably provide effective counseling to the "worried-well" client concerning STI risk and STI prevention. Such counseling, which we have provided often enough to name—"How to be reasonably sexual in the new millennium"—can touch on a number of issues, articulated to a specific clients STI risk, with the aim of guiding effective STI prevention practices and providing appropriate reassurance that can reduce risk of STI and its sequelae, help control STI-related anxieties, and assist in improving sexual health.

Following a familiar permission–limited information–specific suggestions–intensive therapy (PLISSIT) model (Annon, 1976), counseling for the "worried well" whose sexual functioning is compromised by STI-related anxieties might address the following issues.

**STI Prevalence**

An individuals STI risk is a function of his or her specific risky sexual behaviors, the prevalence of a given pathogen in a given epidemiological niche, and the infectivity of specific pathogens, among other factors, and assessment of a clients risk and decisions about counseling emphasis can be approached from this perspective (see Canadian STI Guidelines, 2012a, for discussion of assessment of STI risk).

For the individual who has just returned from vacation and is seeking testing for " . . .

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all the STIs. Now," information about the prevalence of various STIs and the behavior that is thought to have posed risk can guide risk assessment and counseling. For example:

"Im glad you brought that up. And you should know that, having met a new partner on a seniors cruise, with whom you engaged in mutual masturbation, your risk of most STIs is pretty low."

"Im glad you brought that up. Since, as you say, you were in the Caribbean, and some people at the bar shared some kind of pills with you, and you woke up in a bed with naked men and women sleeping around you, and you dont remember exactly

what happened, yes, getting tested for STIs might be a good idea."

For the individual who has just left a heterosexual marriage and "come out," who is experiencing ED, and whose treatment seems complicated by HIV-related fears, the clinical interaction might include the following:

"Im glad you brought that up. Youve said that you are distressed about the changes youve noticed in your erection, that the things weve tried so far havent helped much, and that youre not too interested in the little blue pill. Youve also said that youre looking forward to being openly involved in the gay scene, but that youre very apprehensive about the whole HIV story. There are a couple of reasonable things you might want to do to minimize your risk. Lets talk."

**Condoms**

Most lay persons and many professionals equate condom use with safer sex, and most assume that condom use may be safely abandoned when an individual is in a monogamous relationship with a known and trusted partner. Although latex condoms are a highly effective STI-preventive measure—as are polyethylene condoms for those with latex allergy and female condoms for use by women—there are important limitations concerning condom use for STI prevention. (Note that natural "lambskin"

condoms, made from sheep intestines, are not effective in preventing infection.) First, it is critical to use condoms consistently to prevent STIs. However, inconsistent condom use is common, as is discontinuation of condom use without the benefit of STI testing as relationships become more intimate, despite the fact that intimacy cannot eliminate sexually transmitted pathogens that may have been brought into a relationship by an individuals or a partners sexual history (Black et al., 2009; MacDonald et al., 1990; Misovich, Fisher, & Fisher, 1997).

Second, it is essential to note that condoms prevent some, but not all, STIs.

Counseling concerning condoms needs to take into account the fact that condoms are effective in preventing transmission of some STIs, including HIV, chlamydia, gonorrhea, and syphilis, but not others, such as herpes or human papillomavirus (HPV) 438

infection (Centers for Disease Control and Prevention, 2012a). Moreover, unless condoms are used as a barrier in oral sexual contacts, they cannot prevent the oral transmission of STIs, including herpes, chlamydia, gonorrhea, and HPV. In general, counseling can emphasize that consistent condom use can be an effective and reassuring means of preventing HIV and a number of other sexually transmitted pathogens and should be maintained at least until mutual STI testing, mutual agreement on monogamy, and discussion of how to handle any unintended breach of mutual monogamy (e.g., disclosure to partner, reversion to consistent condom use) have taken place. Counseling should also acknowledge that consistent condom use cannot prevent all STIs, including herpes and HPV.

**Sexual History Taking and Monogamy**

Many laypersons and professionals assume that reviewing a partners sexual history and entering into a monogamous relationship with a known and trusted partner can be effective in reducing STI risk. Counseling must take into account the fact that known and trusted partners may be completely unaware that they are asymptomatic carriers of an STI (Centers for Disease Control and Prevention, 2012b; Canadian STI Guidelines, 2012a), or they may minimize or lie about their sexual or drug use history (Cochran & Mays, 1990). Counseling also needs to take into account the likelihood that a currently monogamous individual may have been serially monogamous, with a history of faithful one-partner relationships that have succeeded one another and that have involved the unnoticed accumulation of STI risk with each serially monogamous partner.

Extramarital and extrarelationship sexual activity is also not uncommon (Laumann, Gagnon, Michael, & Michaels, 1994). For these reasons, STI testing and discussion of monogamy, or maintenance of consistent condom use, may be quite relevant for those who have a sexual history and who are in or entering a monogamous relationship.

**STI Testing**

STI testing is often regarded as a nearly foolproof method of STI prevention if testing takes place before sexual contact with a partner. Although STI testing is advisable and appropriately reassuring in many cases, the sex therapist should keep a number of limitations of STI testing in mind. First and foremost, STI testing generally covers only a subset of STIs, including HIV, chlamydia, gonorrhea, and perhaps syphilis and hepatitis.

STI testing generally does not test for herpes or HPV infection. Second, many individuals assume, incorrectly, that they have been tested for STIs in the course of routine medical care (e.g., "I had a blood test when I had my annual physical," or "Ive donated blood"), whereas in fact STI testing may not have taken place. In addition, STI testing is retrospective in that it tests which of a subset of STIs an individual may have been exposed to in the past, but it is not informative about STI status if the individual or the partner has engaged in risky sexual behavior since the STI test. Finally, the sex 439

therapist should be aware of the "window period" in HIV, syphilis, and viral hepatitis (A, B, C) testing. That is, testing may not be accurate or definitive for a period of time after infection has taken place. For example, HIV testing assesses the presence or absence of antibodies to HIV, which take time to develop following a risky sexual contact. Thus the apprehensive individual who wants to be tested "now," soon after a risky exposure, should be tested for HIV and retested following the HIV window period, some 3 months after his or her last possible exposure to the virus (Canadian STI Guidelines, 2012b).

**Coaching Communication about Condom Use, STI Testing, and Posttest**

**Monogamy**

The sex therapist is generally skilled at coaching clients concerning how to communicate effectively with partners about sensitive sexual and relationship issues and about how to integrate novel sexual practices that have the potential to improve sexual outcomes. These skills may be employed to coach clients about how to bring up and negotiate safer sexual practices, such as condom use, STI testing, and maintenance of posttest monogamy, in their relationships, employing assertive but not aggressive communication strategies. The sex therapist may also need to work with clients to motivate them to communicate with their partners about safer sex issues.

**Specific Suggestions**

The sex therapist may wish to make specific suggestions concerning STI prevention when appropriate to a clients situation. For example, an HPV vaccine is now available for the prevention of cervical cancer and genital warts, and it may be effective in reducing risk of anal cancers as well, which can be of special relevance to gay men and to individuals who engage in anal intercourse (Fisher, 2012). Finally, not to be ignored are routine Pap tests, which serve as secondary prevention of HPV infection-related precancerous and cancerous conditions of the cervix. And, as hepatitis A, B and C may be sexually transmitted diseases, vaccination against hepatitis A and B (no vaccine is available for hepatitis C) may be suggested as well.

**THE BLISSFULLY IGNORANT**

Case Illustrations

A successful 30-something bisexual man consults a sex therapist about a persistent and embarrassing problem with rapid ejaculation that has deterred him from seeking sexual and romantic partnerships. The client reports a new sexual encounter in 440

which the strategies you have taught him have been quite successful.

"The treatment really helped with my vulvar pain—but it didnt save my marriage.

Anyway, Im really looking forward to starting to date again—at the age of 45! Thank you, doctor."

Sex therapists who successfully address a clients sexual problem may unintentionally facilitate their clients acquisition of an STI. Competent clinical practice may include addressing a presenting sexual problem, assessing STI risk of which the client may be aware or completely unaware, and providing effective counseling to minimize STI risk.

Consider the prevalence of HIV infection in the United States in connection with the successful 30-something bisexual male whose distressing problem with rapid ejaculation has been addressed and who is reentering the social and sexual scene (see Figure 22.1).

As a result of the successful introduction of antiretroviral therapy for HIV-infected individuals in the mid-1990s, HIV mortality has dramatically declined. At the same time, HIV prevalence—the number of persons now living with HIV and potentially infectious—has dramatically increased. Despite the fact that adherence to antiretroviral therapy reduces transmission of HIV from infected to uninfected individuals (Granich, Gilks, Dye, De Cock, & Williams, 2009) and despite the fact that HIV prevalence in the United States is far from exclusive to gay and bisexual men, HIV prevalence information provides a basis for some sensitivity to STI risk in this clinical scenario.

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**FIGURE 22.1.** HIV prevalence in the United States, 1981–2008. From Centers for Disease Control and Prevention (2012c).

Consider as well findings for age-specific prevalence of high-risk potentially cancer-causing types of HPV in connection with the 45-year-old woman whose vulvar pain has been successfully treated and who is anticipating returning to the dating scene following her marriage breakup. Roughly 13% of women in this age range show evidence of high-risk cancer-causing HPV infection (Dunne et al., 2007).

In the case of the 30-something bisexual male who is more confidently returning to social and romantic relationships, the sexuality clinician may consider counseling HIV

risk-reduction principles, some of which have been articulated in the preceding section of this chapter. Discussion of condom use, consideration of the advantages of STI testing and monogamous relationships, and HPV and hepatitis A and B vaccination may all be relevant subjects of discussion about tactics that can provide protection and reassurance. Discussion of risk-reduction practices, including serosorting (restricting 442

sexual contact to HIV-negative partners only), strategic positioning (being the insertive, not the receptive, partner may reduce risk), and even use of rapid home HIV antibody tests to screen oneself and ones sexual partner may be relevant as well (Fisher, 2012; Golden, Stekler, Hughes, & Wood, 2008; Parsons et al., 2005). Similarly, in the case of the 45-year-old woman who is returning to the dating scene, counseling concerning STI prevention may be relevant, including condom use, discussion of the advantages and limitations of monogamy, and consideration of HPV vaccination (despite the fact that the woman in question is outside the HPV vaccine target age), hepatitis A and B

vaccination, and continuation of routine Pap tests. The aim of such counseling, of course, is to avoid a situation in which, as noted, successful sex therapy results in the inadvertent enabling of risky sexual behavior.

**THE AFFECTED INDIVIDUAL AND COUPLE**

**Case Illustrations**

A heterosexual couple presents with hypoactive sexual desire disorder (HSDD; female partner) and frequency dissatisfaction (male partner). In their history it emerges that these issues have been of concern during the course of the relationship but have been getting worse, and the sex therapist is advised that she is the "last stop"

before a divorce lawyer. History also reveals that the female partner was treated for chlamydia and pelvic inflammatory disease in her early 20s, a decade prior to the beginning of the current relationship.

A heterosexual couple presents with a sexual and relationship crisis after the female partner reads about the advantages of HPV DNA testing over traditional Pap tests and requests and receives an HPV DNA test from her gynecologist. She tests positive for HPV, and the couple is in crisis. "He gave me an STD!" "She wont touch me!"

Sex therapists will encounter clients and couples who have experienced the sexual and relationship consequences of acquiring an STI. Some clients will shy away from sexual contact because of the residual psychological effects of a past STI of which they have been cured; some will have residual physical effects of a past STI of which they have been cured; and some will experience personal and relationship crises when an STI occurs or appears to occur within the context of a relationship.

In the case of the couple experiencing HSDD and frequency dissatisfaction, their history revealed that past experience with a fertility-endangering STI (chlamydia and pelvic inflammatory disease) may represent a predisposing factor for current sexual distress that is being maintained and exacerbated by couple arguments about sexual frequency. It is possible that individual therapy to process anxieties about the past STI and its sequelae (for the female partner) and providing some insight into partner history 443

as a predisposing factor (for the male partner), as well as therapeutic focus on the HSDD

and the argumentation—exacerbation cycle, may prove helpful to this couple. It is also essential to determine whether the previously "cured" STI has left residual physical effects, such as chronic pelvic pain, provoked by sexual intercourse, that may contribute to the presenting problems of HSDD and frequency dissatisfaction. Such clarification may involve referral to a gynecologist with experience in pelvic pain.

In the case of the couple experiencing a cascade of sexual and relationship distress following an HPV diagnosis, the sex therapist must be knowledgeable about the natural history of HPV infection in order to effectively counsel the couple. Adopting nothing more complicated than an initial PLISSIT approach, the therapist may provide

"permission" for the upset ("Many people would indeed be distressed by this") and address the limited information that has permitted the couple to assume that the HPV

diagnosis represents a newly imported STI from an unfaithful partner. The natural history of HPV infection and its prevalence at midlife suggests the possibility of reactivation of a long latent infection that does not represent introduction of an STI by an adulterous partner ("This is not necessarily a new infection"). What is more, the sex therapist can consider exploiting this crisis to begin processing past and emerging sexual issues with the couple, who—after addressing the HPV crisis—may be interested and open to such couple enhancement approaches.

We wish to emphasize that sex therapists will see couples in whom an STI infection has occurred as the result of extrarelationship sexual activity. In such cases, the individual involved in extrarelationship sex may have disclosed the occurrence of his or her STI to the partner, or, worse, the individual may have infected his or her partner with an STI. Situations such as these can constitute primary relationship crises owing to unfaithfulness, violated trust, and attachment wounds, exacerbated by the impact of the STI on one or both partners. In addition to skill in managing a primary relationship crisis occasioned by infidelity, the sex therapist will need to act knowledgeably in respect to the STI itself by ensuring that the affected individuals have received appropriate testing and treatment and undertaken appropriate preventive actions.

**THE INDIVIDUAL AND COUPLE CONFRONTING A CHRONIC**

**STI**

**Case Illustrations**

An HIV-serodiscordant couple (one partner is HIV infected, one partner is not), both experiencing sexual aversion and both distressed by the years-long disturbance to their relationship that this has occasioned, consult a sex therapist.

A committed heterosexual couple in which the man has recurrent herpes outbreaks and the woman is presumed to be uninfected have significant concerns about sex and marriage and seek assistance from a sex therapist.

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In view of the prevalence of chronic viral STI (see the following discussion), sex therapists may encounter individuals and couples who have chronic STIs, including herpes, HPV, and HIV. Sex therapists can acquire knowledge of the acquisition, natural history, consequences, management, and prevention of these chronic STIs and can integrate this knowledge in providing supportive sex therapy for such clients. Sex therapists may find the biomedical aspects of these situations to be challenging and may elect to comanage them with knowledgeable and supportive medical providers who can contribute to comprehensive care for those experiencing sexual and relationship consequences of a chronic STI. For example, in the case of the HIV-serodiscordant couple, the sex therapist and medical comanagement team might provide comprehensive information about HIV transmission and HIV prevention, including discussion of the effectiveness of condoms in preventing HIV transmission and adherence to HIV antiretroviral therapy as a means of reducing HIV transmission risk, that permits partners to make informed decisions about their desired level of sexual contact and prevention. In the case of the couple considering marriage but distressed and sexually limited by one partners recurrent herpes outbreaks, sex therapy and medical comanagement can also provide information about safer sexual practices, possible suppressive therapies, and realistic appraisal of the risk and the consequences of transmission of herpes as a basis for decision making and action. Following is a case illustration of a relatively complex couple sexual dysfunction that required both intensive therapeutic intervention and comanagement by a sex therapist and a physician experienced in the treatment of HPV infection.

**CASE DISCUSSION: GENERALIZED ANXIETY, UNREALISTIC**

**PORNOGRAPHY, FEELINGS OF INFERIORITY, AND COUPLE**

**SEXUAL DYSFUNCTION**

Mark was a 42-year-old newly married man with a history of generalized anxiety disorder. Treatment for Marks anxiety allowed him to be able to meet and marry Elena, a 40-year-old divorced woman. Mark considered himself inferior to Elena, as he had never had a relationship, whereas she was previously married. Mark generally deferred to Elena on decisions regarding their marriage (where to live, what to do for the holidays). However, Mark felt that Elena was "bossy," and he resented her "control"

over him. Mark also felt that Elena was sexually deficient. Comparing Elena to the women he viewed in pornography and who occupied his fantasies, Mark found Elena overweight, unattractive, and sexually undesirable. Marks previous sexual experiences involved masturbation with pornography, a few "one-night stands," and infrequent visits to prostitutes. As a result of these experiences, Mark has HPV and recurrent outbreaks of genital warts.

Mark and Elena were referred to sex therapy by Marks individual therapist. The couples presenting complaint was that Elena had pain with intercourse. On evaluation, 445

it emerged that intercourse often lasted about 30 minutes, until the intensity of Elenas pain made them stop. On these occasions Mark had not yet ejaculated. Sexual problems worsened shortly after marriage, when Mark told Elena about his HPV infection. Elena was angry that Mark had not shared this information with her. She insisted that they use condoms until Mark was "medically cleared." Mark felt "controlled" but consented to use condoms. During the initial evaluation, it was explained to Mark and Elena that her pain after 10 minutes of intercourse, even with lubricants, was understandable. Marks inability to ejaculate and his obsessive worry about genital warts became the focus of clinical attention.

In individual sessions Mark described the pornography he was viewing. Pornography had given Mark unrealistic expectations of sex and intercourse. Mark had difficulty seeing that the problem was something other than the fact that Elena was overweight and sexually unappealing, whereas the women in pornography were young, sexy, and appeared to be easily orgasmic. Mark acknowledged resentment regarding Elenas insistence on condom use and her "requirement" that he stop viewing pornography.


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Mark also disclosed that his HPV status made him feel inferior to Elena and made his past experiences tawdry rather than successful; and he felt relegated to never being as good as Elena in all facets of their marriage.

Sex therapy began with sensate focus. The early exercises did not involve genital contact or stimulation, and Marks HPV was not a concern. The exercises proceeded slowly, with Mark being increasingly able to attend to Elenas sensual pleasure and Elena being able to learn how to pleasure Mark. Elena learned to communicate more effectively and empathically instead of being instructional. Because the touching was more pleasurable than the sex they had had previously, both Mark and Elena were patient with the slow pace (each sensate focus exercise took 4 weeks and two sessions of therapy).

As the therapy moved toward genital stimulation, Mark began to obsess about infecting Elena, and she worried about this as well. Mark asked Elena to wear latex gloves while stimulating his condom-sheathed penis. Needless to say, whereas Elena experienced considerable pleasure from sensate focus that progressed to include genital stimulation, Mark did not. Elena in fact experienced orgasm for the first time with Mark, an event that pleased her greatly but left Mark feeling that now Elena was also

"better at sex than me." This turn of events was reframed as a sign that Mark was now a good lover, in that he could bring pleasure to Elena.

At this point, the sex therapist suggested a pause in the sensate focus treatment and referred Mark and Elena to a physician with whom he comanaged cases of chronic STI.

The comanaging physician met with Mark and Elena and discussed a number of HPV issues that provided reassurance and reduced guilt. First, the physician conveyed the medical certainty that HPV is extremely prevalent, with something like 60% of sexually active individuals acquiring one or more strains of the virus, often in their first sexual encounter with a sexually experienced partner. Second, the physician discussed recent advances, including findings that condoms may be much more effective than once believed in reducing HPV transmission (Winer et al., 2006) and the possible benefit to Elena and Mark of getting HPV vaccinations, as it was unlikely that they had 446

been infected with all of the vaccine-preventable strains of the virus. The physician also counseled Elena to continue with routine follow-up gynecological care to reduce serious consequences of any HPV infection. Mark and Elena were also informed that his genital warts might spontaneously clear at some point.

In conjoint sessions, Mark and Elena were able to talk to one another about their feelings regarding HPV, and Mark was able to educate Elena about this topic on the basis of further research he had done on the issue, which made him feel that he was taking charge. He also negotiated with her regarding pornography, and they agreed that his pornography use was only problematic when he used it to avoid having sex with Elena. Elena told Mark that she was willing to accept the risk of getting HPV as long as she knew that they were both doing all they could do to minimize the risk of transmission. Sex therapy exercises progressed to include more genital stimulation, including condom-protected oral sex and intercourse. Mark took charge of asking Elena for the kinds of stimulation he wanted: He routinely asked Elena to lubricate the tip of his penis with saliva to increase his sensation and then he put on a condom. Mark was ultimately able to ejaculate intravaginally after 7 minutes of intercourse. He continued to consult his physician regularly to "reality check" his suspicions that he might have a wart. Treatment lasted for 18 months, during which time Mark did not ever have a wart.

Follow-up a year later found that Mark and Elena were having mutually satisfying sex about once a month. Although Mark continued to worry about transmitting HPV to his wife, he was able to act on this concern in a constructive manner, by using condoms and visiting his physician. Both he and Elena now viewed his worry as a sign that he was

"taking charge" of their mutual sexual health.

**AN STI PRIMER: CHARACTERISTICS OF COMMON INFECTIONS**

This section provides an overview of the characteristics of common STIs, grouped by causative agents, and outlines their prevalence, clinical presentation, and measures to prevent, treat, or suppress the infections and their consequences. Further information about characteristics and management of specific STIs may be obtained from the Centers for Disease Control and Prevention (2012b) and Health Canada (2012).

**Bacterial STIs**

Chlamydia, gonorrhea, and syphilis are caused by bacteria, and a defining characteristic of bacterial STIs is that they may be cured by antibiotic treatment. Early detection and treatment of bacterial STIs may prevent their more serious medical consequences.

**Chlamydia**

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Chlamydia trachomatis is a prevalent bacterial STI in both women and men and is most commonly transmitted via penis–vagina and penis–anus sexual contacts, although oral sexual transmission is also possible. Young heterosexual males and females have the highest rates of chlamydia (Centers for Disease Control, 2012d; Fisher & Steben, 2014).

More than two-thirds of chlamydia infections are asymptomatic; some chlamydia infections will present with a mild discharge from the vagina, penis, or anus, and urinary symptoms (burning or itching) in men and women and vaginal bleeding after intercourse in women may also be present.

Chlamydia can cause pelvic inflammatory disease (PID), fallopian tube scarring, ectopic pregnancy, and infertility in women (Baraitser, Alexander, & Steringham, 2011).

Chlamydia also manifests itself in urethritis (inflammation of the urethra) and epididymitis (inflammation of the epididymis), with penile discharge or scrotal pain in men. Chlamydia has historically been diagnosed in women by doing a pelvic examination and swabbing the cervix or by swabbing the mans urethra. The development of urine testing for chlamydia has made screening for infections much easier and less intrusive. Chlamydia can be prevented with consistent use of latex condoms and is curable with antibiotics.

**Gonorrhea**

Gonorrhea is the second most common bacterial STI. It is transmitted in penis–vagina and penis–anus sexual contact and may be transmitted in oral sexual contact as well (Centers for Disease Control, 2012b; Fisher & Steben, 2014). It is commonly found as a coinfection with chlamydia (Sadeghi-Nejad, Wasserman, Weidner, Richardson, & Goldmeier, 2010). Gonorrhea is most common in men who have sex with men (MSM)

and individuals who have had sex while traveling abroad and is less common, though increasing, in heterosexual individuals. Gonorrhea is more often symptomatic than chlamydia, with a more pus-like yellow–green genital discharge than in chlamydia.

Medical consequences are similar to chlamydia for both men and women, with acute PID symptoms in women being more severe with gonorrhea. PID can lead to deep dyspareunia for women. Gonorrhea can be prevented with consistent use of latex condoms and is curable with antibiotics.

**Syphilis**

Syphilis presents with a painless genital ulcer. When syphilis is left untreated, it becomes asymptomatic and latent—while remaining infectious—for decades (Centers for Disease Control and Prevention, 2012b; Fisher & Steben, 2014). Late manifestations of syphilis cause myriad symptoms, including cardiac and neurological problems. Syphilis can be transmitted from mother to infant. Syphilis is uncommon in the general population, though it is more frequent in MSM, in travelers who have had sex in endemic areas, and in individuals having sex in areas with geographic outbreaks. The incidence of syphilis 448

has also been increasing among heterosexuals, with the greatest increase in the United States among black and Hispanic men ages 20–29 (Su, Beltrami, Zaidi, &Weinstock, 2011). Syphilis can be prevented with consistent use of latex condoms and is curable with antibiotics.

**Viral STIs**

**Herpes Simplex Virus**

Herpes simplex virus (HSV) is quite common and causes painful blisters on the genitals that ulcerate, crust, and gradually heal (Centers for Disease Control, 2012b; Fisher & Steben, 2014). Historically, HSV type 1 (HSV-1) was localized around the mouth, causing "cold sores," while HSV-2 caused genital herpes. These divisions have blurred over the past decades and have little clinical relevance today. Herpes can be transmitted during oral, vaginal, and anal sex, and it can be transmitted to infants during childbirth.

It is transmissible while the individual is symptomatic or during asymptomatic periods when the individual may still be shedding virus. Herpes outbreaks can recur, though subsequent outbreaks gradually become less frequent and less painful. Both primary and recurrent events lead to painful sex, as well as fears of passing on the infection. Xu et al.

(2006) report that 17% of Americans ages 14–49 had evidence of HSV-2 infection, with 90% not knowing that they had contracted it. HSV may occur in women who have had sex with women (Marrazzo, 2010).

HSV screening of asymptomatic individuals is not routine, and management and prevention implications of a positive HSV test for the individual and his or her partner are not clear. The adverse psychological effect of being screened positive for HSV has been rated as similar to that of a minor automobile accident (Richards et al., 2007).

Reduction of the burden of genital herpes through screening and subsequent adoption of either safer sex practices or continuous suppressive antiviral therapy has not been proven. Antiviral drug treatment at the first sign of an outbreak can reduce outbreak symptoms. For those with recurrent attacks, continuous use of medications reduces morbidity, as well as decreasing viral shedding and partner infectivity (Mindel & Marks, 2005). People with recurrent genital herpes can reduce the risk of passing HSV to their partners by using latex condoms. Abstention during an outbreak still carries a 5%

annual partner infection rate due to asymptomatic shedding of viral particles. This rate can be halved if the infected partner takes ongoing antiviral medications (Corey et al., 2004).

**Human Papillomavirus**

Human papillomavirus (HPV) is an exceedingly common sexually transmitted infection (Dunne et al., 2007; Fisher, 2012; Giuliano et al., 2011; Richardson et al., 2003; Winer et al., 2006) that may have serious medical consequences (Palefsky, 2010; Parkin & Bray, 449

2006). HPV prevalence among U.S. women ages 14–59 is estimated to be 26.8%, with both low-risk HPV types (15.2% prevalence), which can cause genital warts, and high-risk HPV types (17.8% prevalence), which can cause cervical, vaginal, penile, anal, and head and neck cancers, quite common (Dunne et al., 2007). A recent multinational study of men ages 18–70 showed a 50% prevalence of HPV infection in men, with 38%

prevalence of low-risk types and a 30% prevalence of high-risk types (Giuliano et al., 2011). The medical consequences of HPV infection, including genital warts and precancerous changes of the cervix, which require investigation and treatment, are common as well.

The approval of two HPV vaccines in recent years offers the potential to prevent most cervical cancer and genital warts and possibly other HPV-related conditions as well. Gardasil, which prevents infection with the most common cancer-causing and wart-causing HPV types, and Cervarix, which prevents infection with the most common cancer-causing HPV types, are presently available. HPV vaccine is approved for immunization of girls and women ages 9–45 for the prevention of cervical cancer and genital warts and for boys and men ages 9–26 for the prevention of genital warts. It may also be of benefit to older individuals depending upon individual circumstances. For example, a middle-aged male or female who is leaving a 20-year-long relationship and reentering the dating scene may wish to speak with his or her health care provider about the potential benefit of HPV vaccination. Note that HPV vaccine may be of benefit to individuals who have already been sexually active, as acquisition of all vaccine-preventable HPV types has not necessarily occurred. In addition to prophylactic vaccination, latex condom use may reduce the risk of HPV infection (but not entirely, as HPV infects areas of the body not covered by condoms; see Winer et al., 2006, for findings concerning condom protection from HPV infection). Treatment of HPV-related medical conditions, but not cure of the virus per se, is possible.

**Human Immunodeficiency Virus**

Human immunodeficiency virus (HIV) is passed from an infected to an uninfected individual in penile–anal (highest risk), penile–vaginal (high risk), and oral sex (low risk but not risk free) contacts; through sharing paraphernalia for intravenous drug use; and from mother to infant (Centers for Disease Control and Prevention, 2012b; Fisher & Steben, 2014). Any sexual or drug-injection activity that has the potential to transfer bodily fluids, particular semen, vaginal fluid, or blood from one person to another poses risk for HIV infection. HIV infection, if untreated, leads to compromise of the immune system, opportunistic infections, and very high mortality. Highly active antiretroviral therapy (HAART), developed in the mid-1990s, represents an effective treatment for HIV that has turned the disease into a chronic manageable condition that requires a high degree of adherence to the drug regimen over the lifespan. Individuals adhering to HAART may be much less infectious to others, though this depends upon adherence to medication and therapeutic efficacy in lowering the individuals viral load (Granich et al., 2009). The U.S. Centers for Disease Control reported that at the end of 2009 there 450

were 784,701 people living with HIV in the 46 reporting states, meaning that about 1

million Americans are living with HIV (Centers for Disease Control and Prevention, 2012c) and that a significant proportion of people living with HIV are not aware that they are infected.

Male-to-male sexual contact, injection-drug paraphernalia sharing, and heterosexual contact are all relatively common routes of HIV infection, with male-to-male contact the most common route of infection among men. Heterosexual contact and intravenous-drug paraphernalia sharing are the most common routes of HIV infection among women (Centers for Disease Control and Prevention, 2012b). Latex condoms are effective in preventing HIV infection, and avoidance of risky sexual practices, mutual HIV testing, partner serosorting, and viral load lowering via adherence to HAART are all harm-reduction possibilities (Fisher, 2012). The use of postexposure prophylaxis with HAART for individuals who have experienced sexual assault, and potentially for those who have simply had unprotected intercourse, should also be explored when indicated.

HIV antibody testing can be used to screen or test for HIV infection. We again note that HIV testing detects antibodies to infection and is regarded as definitively negative only when conducted some 3 months after an individuals last potential exposure to risk.

**Hepatitis**

Hepatitis A, B, and C are viral infections that can cause liver disease and can be sexually transmitted (Centers for Disease Control and Prevention, 2012d; Fisher & Steben, 2014).

Hepatitis A and B are relatively common among MSM, and hepatitis C is relatively common among HIV-infected MSM. Hepatitis may also be common among individuals

who share injection-drug paraphernalia and among individuals who come from countries in which the infection is endemic. Chronic hepatitis B can lead to cirrhosis and is a common cause of liver cancer. The lag time between exposure to hepatitis via intimate sexual, blood, or fecal contact may make it difficult for patients to know how, or from whom, they contracted the infection. Hepatitis A and B are vaccine preventable.

Most schoolchildren in North America have received hepatitis B vaccine in school-based vaccination programs, and the rate of new hepatitis B infections has declined by 82% in the United States since 1991, when the recommendation to routinely vaccinate all children was introduced (Centers for Disease Control and Prevention, 2012e).

**Other Genital Concerns**

**Trichomonas Vaginalis**

Trichomonas vaginalis (Centers for Disease Control and Prevention, 2012b) is a protozoan infection that is often transmitted sexually but can be contracted nonsexually.

Trichomonas is often asymptomatic, but it can cause symptoms similar to yeast infections in women and can cause burning on urination or ejaculation in men and 451

discomfort during sex for both men and women. It can be transmitted in both heterosexual and same-sex sexual contacts; condoms can help prevent trichomonas but not with complete effectiveness. Trichomonas can cause preterm labor and low-birth-weight infants and can be treated with oral antibiotics.

**Vulvovaginal Candidiasis**

Vulvovaginal candidiasis, or "yeast infection," is caused by the overgrowth of bacteria that normally live in the vagina (Centers for Disease Control and Prevention, 2012f). Up to 75% of women will experience a genital yeast infection at some point in their lives, with up to half of all women suffering more than once. Yeast vulvovaginitis is characterized by vaginal irritation and itching, a white discharge, and inflammation and redness of the vaginal mucosa. Vulvovaginal candidiasis is not an STI per se. A sizable increase in risk of genital yeast infections does occur when women become sexually active, but sexual intercourse itself, and the frequency of coitus, are not clearly causative agents (Sobel, 2003; Sobel et al., 1998). Antibiotics can also cause vulvovaginal candidiasis. Men can get yeast infections on the glans penis, especially if they are uncircumcised. For both sexes, vulvovaginal candidiasis can lead to painful intercourse.

Genital yeast infections can be treated with both topical and oral medications. Treating both partners can prevent "ping-pong" reinfections.

**IMPACT OF STIs ON SEXUAL AND RELATIONSHIP FUNCTION**

Systematic evidence concerning the impact of STIs on sexual and relationship function has begun to appear in the professional literature in recent years (Fisher, 2012; Goldmeier & Leiblum, 2005; Graziottin & Serafini, 2009; Sadeghi-Nejad et al., 2010).

With respect to the impact of bacterial—and therefore curable—STIs on sexual and couple relationships, Gottlieb and colleagues (2011) recruited women testing positive for chlamydia at a U.S. midwestern family planning clinic. Approximately 90% of these women felt that it would be difficult to trust future partners, 7 out of 10 felt betrayed by their current partners, and 1 in 3 women who tested positive for chlamydia reported breaking up with their partners the following month. More than 75% of the women who tested positive for chlamydia reported that they "were not very proud" of their actions, more than 50% felt guilty that they might have infected someone else with chlamydia, and one in four of these women were very scared about telling their partners about their infections. Gottleib et al. (2011, p. 1009) note that "tailored counseling might minimize psychosocial impact. For example, discussing the fact that most people are unaware that they have Chlamydia and that infection may last for > 1 year may help to alleviate concerns about partner fidelity and trust for some patients." The clinical wisdom of emphasizing the ambiguity of timing of a chlamydia infection, a point also raised by Duncan, Hart, Scoular, and Bigrigg (2001), may depend upon the specifics of an 452

individuals and couples situation. The clinician would not necessarily want to obscure an incident of infidelity that resulted in the importation of chlamydia into a relationship, nor would the clinician wish to encourage this conclusion if unwarranted by ambiguous timing of infection. The issue of possible harm resulting from false-positive results in low-prevalence populations has also been discussed by Gottleib et al.

(2011) and Sadeghi-Nejad et al. (2010).

With respect to the impact of viral—and therefore manageable but not curable—STIs on sexual and relationship health, recent research on the effects of HPV infection is informative. Sexual and relationship impact of HPV infection may stem from the infection and its clinical symptoms, from anxiety about transmission of the virus to or from a sexual partner, from extended, painful, and sometimes ineffective treatment of symptoms, or from all of these (Linnehan & Groce, 2000).

Research on men and women recently diagnosed with HPV-related anogential warts indicates that this condition has a significant negative impact on quality of life, mental health, and sexual health measures (Drolet et al., 2011a). The negative impact of anogenital warts on these factors dissipated among those whose warts cleared during a prospective arm of study but remained elevated among those whose warts had not resolved. Women with HPV-related abnormal Pap tests have been found to experience significant negative impact on quality of life and mental health, as well as negative impact on their sexuality and concerns about their partners and HPV transmission (Drolet et al., 2011b). HPV-infected women report stigma (e.g., "I feel the need to hide the fact that I have HPV"), shame (e.g., "I am ashamed of having HPV"), self-blame (e.g.,"With HPV, I feel that I am paying for past behaviors"), and feelings that "my body is disgusting to me" and of being "unclean" (Daley et al., 2010, p. 285). In related findings, McCaffery and colleagues (2004) found that HPV-infected women felt worse about their current sexual partners, worse about their past sexual partners, and worse about their future sexual relationships, compared with uninfected women. Sexual disturbances have also been reported by women who have HPV infection and cervical intraepithelial neoplasia (CIN), precancerous cervical changes. Campion and colleagues (1988) found that HPV-infected women with CIN reported significant decreases in sexual desire, sexual frequency, sexual arousal, and orgasm, as well as greater discomfort and more negative feelings about sexual intercourse, 6 months after treatment.

Findings for the negative psychosexual impact of HPV infection in women may be of considerably increased significance to sex therapists in coming years. HPV testing is currently being phased in as a routine measure to augment or replace the traditional Pap smear for detecting precursors of cervical cancer (Cuzick et al., 2006). As a consequence of routine HPV screening, we anticipate that a substantial number of women and their partners will have to deal with psychosexual sequelae of an HPV diagnosis.

Systematic research on psychosexual consequences of other viral STIs, including genital herpes (e.g., Melville et al., 2003; Mindel & Marks, 2005) and HIV (Sadeghi-Nejad et al., 2010; Shindel, Horberg, Smith, & Breyer, 2011; Jena, Goldman, Kamdar, Lakdawalla, & Lu, 2010) has also been reported in recent years. In a review of the literature concerning psychosexual consequences of genital herpes infection, Mindel and Marks (2005) conclude that the "studies suggest that, at presentation, at least some 453

patients with genital herpes will have psychological and psychosexual problems and that these may be more clinically significant and more common than those occurring in patients routinely attending genitourinary medicine departments with other complaints.

. . . Individuals with many recurrences continued to be anxious and concerned, as they had been at first visit" (Mindel & Marks, 2005, p. 306). These authors also review research on management options, including psychoeducational approaches and suppressive antiviral therapy for ameliorating the negative psychosexual impact of genital herpes, and report favorable evidence for the latter approach. This may suggest the utility of comanagement of the psychosexual sequelae of genital herpes with a medical provider experienced in this area.

The possible sexual consequences of HIV infection have been the subject of a number of studies (e.g., Shindel et al., 2011) and have been reviewed in detail by Sadeghi-Nejad and colleagues (2010). This review concludes that rates of sexual dysfunction appear to be sharply elevated among HIV-infected MSM compared with uninfected MSM and among HIV-infected women compared with uninfected women. Causes of sexual dysfunction among HIV-infected individuals may include affective disorders associated with HIV diagnosis, direct effects of HIV infection on sexual function, and effects of HIV treatment that result in distinctive body fat accumulations, body image disturbance, and visible disclosure that the individual is infected, as well as HIV-associated hormonal disturbances and HAART-associated iatrogenic HSDD. Critical issues for sex therapists treating HIV-infected individuals and HIV-discordant couples are several. First, sex therapists may need to increase awareness that their scope of practice could include welcoming HIV-infected individuals and HIV-affected couples and bringing to bear sex therapy skills in assisting such individuals and couples with issues of sexual adjustment. Second, whether for an HIV-infected individual or an HIV-discordant couple, counseling and coaching may be in order in connection with managing sexual relationships and avoiding transmission of infection. Third, addressing HIV-related and HIV-unrelated sexual disturbances will require clinical judgment about predisposing and maintaining factors without necessarily concluding that HIV infection is the primary factor at play. Fifth, active management of safer and risky sexual behavior with HIV-infected individuals may be a significant clinical objective (Fisher et al., 2006).

Finally, active comanagement with HIV care medical personnel may be a desirable option. The creation of clinical liaisons that increase awareness in the HIV-affected community that there is a source of professional support for HIV-related sexual function and relationship challenges would be a welcome addition to the sex therapy and HIV care landscape.

We note in closing this section on psychosexual impact of STIs that we have observed that the effect of an STI on sexual and relationship health is heavily influenced by the meanings that the individuals involved ascribe to the infection. At some level, it is the role of a therapist working with a couple dealing with an STI to help each individual make meaning of the diagnosis. An STI arising within a relationship may appear overwhelming to many. Helping a couple find perspective and acknowledge the other dimensions and connections of their relationship may help them move forward. The diagnosis of an STI is often a crisis for the couple. In addition to myriad negative 454

impacts, such a crisis may provide an opportunity for the couple to start dealing with secrets, improve communication, and deal with shame and hurt. Therapists can help both members of the couple generate a new narrative as they work to move forward with their new reality.

**SEX THERAPY, STIs, AND ETHICAL AND LEGAL**

**RAMIFICATIONS**

Sex therapists need to be knowledgeable and respectful of their particular disciplines and jurisdictions rules with respect to situations in which the clinician becomes aware of STI transmission risk behavior. Such professional and legal regulations differ across differing jurisdictions and must be considered and respected.

**CONCLUSIONS**

We conclude our discussion with a summary of STI counseling principles in the sex therapy setting.

1\. Sex therapy may unintentionally enable sexual behavior in clients who are unaware of their STI risk. The sex therapist should assess STI risk for all clients and counsel STI prevention strategies as appropriate.

2\. Assessing STI risk behavior and the epidemiological setting of such risk behavior can guide evaluation of a clients level of risk and suggest appropriate prevention and testing strategies.

3\. Monogamy with known and trusted partners is not necessarily an effective STI prevention strategy.

4\. Latex condom use may be a reassuring method of prevention of STI. However, condom use must be consistent; it effectively prevents some STIs, but not others; and condoms do not prevent oral transmission of STI unless employed as a barrier in oral sexual contacts.

5\. For optimum STI prevention, latex condom use should be maintained at least until mutual STI testing, joint agreement on monogamy, and discussion of how to handle any unintended breach of mutual monogamy have taken place in couples

in which one or both partners have been sexually active in the past.

6\. STI testing can be an effective and reassuring means of STI prevention if testing takes place prior to sexual contact and if posttest monogamy is adhered to. STI testing, however, can detect some but not all STIs; it is retrospective; and the HIV–

hepatitis–syphilis window periods may be factors in relying on STI test results.

7\. Sex therapists may employ existing counseling skills to rehearse and motivate safer sex client—partner communication concerning condom use, STI testing, posttest

monogamy, and incident STI infection.

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8\. Specific suggestions, including HPV vaccination, hepatitis A and B vaccination, and reminding sexually active women about the importance of routine Pap tests, should be considered.

9\. Sex therapists may find that management of the sexual and relationship impacts of STIs benefits from comanagement with knowledgeable and supportive medical providers who can contribute to comprehensive care for those experiencing consequences of an infection.

10\. Laboratory tests for STIs can identify the infective agent but cannot always definitively state when the infection was contracted or who gave it to whom.

11\. Sex therapists may deal with couples in whom an STI acquired historically surfaces within a sexual relationship. They can inform clients that the infection is historical and does not represent an importation from an unfaithful partner. Sex therapists may also deal with a situation in which an acute STI acquired in extrarelationship sexual contact provokes a primary relationship crisis exacerbated by the STI.

12\. An STI arising in a relationship appears overwhelming to many. Helping a couple find perspective and acknowledge the many other dimensions and connections of

their relationship may help them move forward.

13\. The role of a therapist working with a couple dealing with an STI is to help each individual, as well as the dyad, make meaning of the diagnosis.

**CODA**

Im dealing a lot better with my situation since my original e-mail, largely brought upon the support of the people I chose to share the news with and with the information I got through you. The realization that life will and has continued on as it did before, for the most part, helps in dealing with this. . . . Still a lot of anxiety in relation to the possibility of a future outbreak, not knowing when it may come, how bad it will be, and being aware perhaps too much of signs that another outbreak is coming. The only other source of anxiety is associated with fear surrounding the idea of even entering the dating scene again (and even though Im in a happy relationship theres a lot of pressure to make sure this relationship works out, just to avoid finding someone else while having the STI. I see this as not so problematic for me personally but could see how some women may be influenced to stay in an abusive/bad relationship because of this). Also upon talking with some close friends about it I found out one had had a run in with a treatable STI in the past and another who had a friend who had gotten genital warts. Hearing that Im not the only one was sort of helpful and as it turns out my story has convinced all my friends to consistently use condoms so thats a silver lining as well, as much worse STIs are out there and I would hate any of my friends to catch them. Only other thing I can think of is that there is still a minor effect on my sex life, as oral sex is still off limits (and was previously enjoyed) but other than that most things remain the same.

456

—ANONYMOUS (personal communication, 2011)

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