Bad medicine: sexual health medicineBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e8643 (Published 02 January 2013) Cite this as: BMJ 2013;346:e8643
- Des Spence, general practitioner, Glasgow
The “clap clinic” has moved from a Portakabin behind the hospital bins to shiny new buildings. Today sexual health is jeans wearing, eyebrow pierced, cool medicine. This is to be celebrated, but care is still regrettably concentrated in secondary care and testing is restricted. But what is concerning about sexual health is its tyranny of terror messages: these are weapons of mass destruction of relationships.⇑
Consider HIV. In the 1980s we lived in constant fear of being crushed to death by colossal falling tombstones. HIV testing was allowed only after counselling and in distant specialist centres. This policy served only to reinforce the stigma of HIV. The legacy is that today many general practitioners are still reluctant to test for HIV. And this belies the truth that HIV is rare in low risk heterosexual populations, with only 50001 people with undiagnosed infection in the UK. So for a low risk couple unaware of their HIV status, the risk of contracting HIV from one act of unprotected intercourse is more than a million to one, assuming a prevalence of 1 in 1000 and risk of transmission of 1 in 1000.1 2 This is not no risk but very low risk, and couples need proportionate advice. Also HIV is treatable: treatment reduces transmission greatly,3 and there is near normal life expectancy. HIV is no death sentence.
Other sexually transmitted infections are common but asymptomatic. Presenting genital herpes as a serious, lifelong, incurable infection misrepresents the truth. In the United States it affects perhaps 30% of the population, and the prevalence is stable.4 5 And herpes is treatable, an inconvenience but no life sentence.
As for chlamydia the message is one of increasing prevalence and increasing risk of infertility. But the epidemiology is poorly understood. Chlamydia clears itself, and the rise in prevalence is an artefact of new testing. The lifetime prevalence is perhaps 30%.6 Chlamydia is treatable, complications rare,7 pelvic inflammatory disease is declining,8 and infection does not increase risk of infertility.9
As for human papillomavirus (HPV), the lifetime prevalence is “at least 50%” of the population10; those who actually develop warts are merely unfortunate. HPV is not a stigmatising infection but almost a normal consequence of sexual activity. Yet new diagnoses of these infections are devastating in relationships, bringing suspicion and needless anxiety.
We should promote safe sex but normalise positive results and reassure more. Increasing access to testing is key, and we should encourage routine home testing.11 The vast majority of infections can easily be managed in primary care. These changes have the potential to actually destigmatise sexual health and improve infection control. A medical culture based on fear is always bad medicine.
Cite this as: BMJ 2012;345:e8643
Provenance and peer review: Commissioned; externally peer reviewed.
Follow Des Spence on Twitter @des_spence1