Body Matters: The Taboo Around STI Testing
In ‘Body Matters,’ we explore the lived experiences of OB-GYN patients in India who defy stereotypical gender expectations and challenge what it means to be a body that matters in medicine.
Sexually transmitted infections (STIs) — in India and elsewhere — are fraught with the most culturally-loaded meanings. They seem to imply promiscuous sexual habits, deviations from family values, and a morally dubious departure from gendered and heteronormative ideals. Therefore, testing for STIs as a medical condition becomes especially difficult in a context where sex is still overwhelmingly associated with monogamous, heterosexual marriages.
Two patients, S. and P. explain what misplaced understandings around sex look like in medicine, and one doctor, Dr. Renuka Dangare, outlines the implications.
When Lack of Testing Leads to Prolonged Treatment, Misleading Information
S: I had genital warts, for which I went to three gynacs. The first [doctor] did not diagnose them as she never bothered to examine the [vaginal] area and just inserted a piece of equipment to test for fungal infection. Since the main concern was not the infection, but warts, an anti-fungal treatment did not work. When I told her I was diagnosed with warts on the second visit, she said that a dermatologist is the right consultation I need.
He [the dermatologist] told me that warts are caused by the human papillomavirus infection (HPV) and that 80% of the sexually active population has HPV. He added there was nothing too serious about the condition, and there was no need for surgery. The doctor prescribed a 10 days course of liquid solution application; I applied it for two days, and it helped treat warts.
The HPV that causes warts is 100% non-cancerous; however, my two gynacs scared me and said a sample wart will have to be sent to the lab for examination to check whether its cancerous or not. Information about warts & HPV is essential. People don’t know much, get scared, and end up spending a lot of money on surgery.
Dr. Renuka: In India, preventive care is coming up now, but there are a few barriers to that whole process. Only premarital counseling or marital counseling usually involves these conversations [about sex and STIs] because these are spaces where patients feel comfortable talking about their sexual history. But in other scenarios, when you go for a preventive visit, you don’t explicitly talk to your doctor about this. If someone goes to a gynac to get themselves checked and the gynac feels this is a vaginal infection, and from the patient’s side, if there is no hint at all, I am very less likely to assume that you are sexually active or that you are unsafe. So the assumption is you may not want to get tested at all.
The time it takes for diagnosis depends greatly on the STI; you can go undiagnosed for months on end. I know an individual who got hepatitis B through a needle when they were three years old, and they never had more than one partner. This individual got diagnosed [with an STI] at 32; the only reason they got diagnosed is that their liver enzymes were high, and the doctor was like, okay, let’s confirm why they’re high. You can go undiagnosed for years.
Chlamydia and gonorrhoea can have no symptoms at all. They can have some itching or discomfort at the vulva. On the other hand, trichomonas is associated with copious amounts of vaginal discharge that can be itchy and smelly; you end up thinking it’s just something that needs to be treated with intimate washes. Other STIs like hepatitis and HIV may not cause any genitals symptoms. The first signs of hepatitis B are nausea, so it’s very less likely that you will think about that as your symptom of an STI.
When Doctors Do the Wrong Thing
S: When I consulted another gynac, I immediately went into panic mode when he examined me. I was triggered by his reaction; he was aghast and expressed the same with an unprofessional level of expression. He diagnosed the warts, but he said the only viable way to treat them was through an excision surgery that would cost me Rs. 40,000. He also said that my partner was sleeping with more than one person simultaneously, which could be the only cause of the infection. I left there in a state of numbness and guilt; I wasn’t alert enough to ask the general questions any prudent patient would ask. I needed a confirmatory consultation since the diagnosis was a big one for me; I had never heard of warts and no one ever educated us about it since our country equates sexually active only if married.
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Dr. Renuka: The point at which somebody approaches, and can explicitly start talking about their sexual history, is only after marriage and when they’re looking to conceive a child. We do get all these tests done at that time… because a lot of times, gonorrhea and chlamydia can cause irreversible infertility. These tests should be done more regularly.
When Access to Testing Becomes Lifesaving
P: In December, I thought I should get tested for HIV; I last had it in 2014. The prime focus was to visit a government facility to learn how it works. I went to this hospital in Nashik, and it was a National AIDS Control Organization (NACO) center. The doctors tried to dig and ask what I wanted to get tested for; I explained that it was a random test and that they should be okay with it. They did not agree to it.
Dr. Renuka: [Whether an STI gets serious or life-threatening] really depends on your immunity. If you are someone who’s contracted hepatitis B and refuse to get checked for it, you could get liver cirrhosis in very odd cases; in 5% of cases, you could get liver cancer. If you’re someone with HIV, who is not getting tested, and whose viral load is out of control, yes, you could die out of complications due to HIV. If you are someone who has chlamydia or gonorrhea, you could get infertility and a really bad pelvic infection that could cause high morbidity, if not mortality.
STI testing should become a part of preventive screenings. But again, it’s such a sensitive issue that it needs to be introduced gradually. It should start with creating a space where patients are more comfortable discussing sex and sexuality, and also a space where you can sex educate your patient. That’s where you can bring in STIs. Because unless that comfort level is created, patients will not disclose things to you.
You can ask about how long they’re with their partners, if it’s an open relationship; basically, anything for us to ascertain if the patient needs to get tested again. And then finally, from a preventive point of view, you should be able to talk to them about vaccines. So, if somebody indulges in oral sex, particularly oral-anal, you want to ask them about hepatitis A, HPV, and hepatitis B vaccines. If someone is a very high-risk person in multiple open relationships, and those partners are also in multiple open relationships, you can talk to them about PrEP, or pre-exposure prophylaxis, which is like HIV preventive therapy.
When Doctors Make Assumptions
S: I took my best friend with me for my third consultation so that I don’t freeze out of fear. I handed to her a list of questions I made beforehand. The doctor had an experience of more than 25 years; they seemed warm. But she immediately became judgmental when I told her my current sexual partners involved one male and one female (all consensual from each and transparent, just not all three together); she was taken aback. I got uncomfortable, changed the topic, and said no, I had just one male partner. She, too, said the same thing: the only route [to addressing my infection] is excision surgery, which would cost Rs. 50,000 after one week’s medicine course and tests.
It is impossible that gynacs, with over two decades of experience, did not know that a dermatologist is the right consultation, and surgery is not the only way to treat warts.
P: All the people who visit NACO are those who have been told to take the test — not those who take it voluntarily. They [doctors] are not expecting someone young to get tested voluntarily. I told them I’m sexually active with my partner and therefore want to get tested; they asked if my partner is also tested. There were five-to-six employees in the clinic, and everyone looked at me [strangely]; it was a different scene altogether. As a doctor myself, I know this system and was not taken aback. But if there’s someone from a non-medico background who wants to get tested voluntarily, this entire experience will leave a terrible impression on them.
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Dr. Renuka: We don’t really have super-specific protocols for asymptomatic patients and screening of STIs. To my knowledge, what protocols exist are to check if a person is symptomatic, or if a person has a known exposure, and then encourage testing. The only space where we encourage early prophylactic testing is in pregnant persons because we want them to not pass it on to their unborn offspring. That’s what’s being done so far. But some protocols exist in the west around proactively testing for STIs, and getting people to test every few years or things like that.
In Western culture, it’s assumed that you are sexually active — unless you mention otherwise. It’s exactly the opposite side in India. From the doctors’ side, there is this issue of always having assumed that an individual is like a responsibility of their parents. A lot of doctors are thus stuck with completely separating a patient and a parent’s identities. That’s one of the biggest fears in today’s day and age that stops doctors from completely maintaining patient’s privacy. I think that’s a roadblock that also dissuades young adults from disclosing their sexuality to their doctors.
As doctors, should we encourage proactive STI testing? 1,000% we should. Unless we remove the taboo around sex in this country, it will be tough to address the public health problem [of low STI testing]. If we talk more about sex and impart a proper comprehensive sex education within the schooling systems, it will certainly help. If you relax regulations, and let people talk about sex, the discourse around STIs will change.
The above insights were obtained from two anonymous patients and one doctor — all of whom had vital things to share about what the doctor-patient relationship should not look like, and a roadmap for what it should look like. The narratives here are as told to The Swaddle, and are preserved for maximum authenticity of lived experiences. They have only been edited and organized thematically for the sake of clarity and conciseness.