I wish I could say that this post is about cleanliness. That would be a really simple topic. Clean is good; dirty is to be avoided with the judicious use of soap and water. End of story.
Yet is isn't that kind of clean that I am speaking about. It is about a use of the word that sets me off whenever I hear/read it. Let me explain.
Too many times I have heard people being describe their sexual partners as being clean. As in, "I don't have to worry about STIs (sexually transmitted infections) as long as I pick a clean partner." And what the hell does this mean? Someone who just got out of the bathtub? Someone who really, really, really likes soap? Because methinks this use of the word clean is indeed a mistake.
As someone who has spent years working with the diagnosis, testing and treatment of STIs, I find this concept of clean to be both fascinating and ridiculous. It is not uncommon for people to assume that those with STIs are dirty, promiscuous, and fill-in-the-blank-with-the-derogatory-term-of-your-choosing. It is a way of separating yourself from them. They did bad things and suffered the consequences, but that would never happen to me because I'm clean and so is my partner. I've heard so much about being clean from my teen patients, their parents and other adults on health boards that I used to moderate that I always had to ask, "how do you know that someone is clean?"
Their answers demonstrated their lack of knowledge about STIs in general.
- S/he doesn't sleep around
- S/he goes to church
- S/he went to the doctor and got "checked"
- S/he is a good person
Let's explore each of these in turn.
S/he doesn't sleep around
What is the definition of sleeping around? What I've found is that no one ever thinks that his/her sexual behavior constitutes sleeping around. Sleeping around is something those dirty people do. Even the 16 year old boy who told me that he had had 500 partners (clearly he had to have started having sex when he was in the cradle) did not feel that he was sleeping around. So who defines what constitutes sleeping around?
Some in the STI research area classify having more than 5 lifetime partners as being "high risk."1(All those with less than 5 partners breathe a sigh of relief.) Would having over 5 partners be the definition of sleeping around? If so, I guess that would make me a ho. A real ho. That notwithstanding, there are tons of people with only 4 or 3 or 2 or even 1 lifetime partner who acquire STIs, so the sleeping around standard seems to have a lot of holes.
S/he goes to church
Do I even need to touch this one? I don't think so.
S/he went to the doctor and got "checked."
Here's information that most people don't know. It is not possible to be "checked" for every STI. Half the time you are not being tested for what you think you are being tested for. Next, there is no test to say you don't have HSV or HPV. Thus getting "checked" doesn't mean that you are disease-free. How does a sexually active person ever know that he or she is disease free? They don't. There is no guarantee or clean bill of health that can be given in this arena. Sex is a calculated risk. You've just got to decide who's worth rolling the dice for. And despite all good intentions, you can still crap out. That is the fact.
S/he's a good person
Good people don't get STIs. There seems to be some need, some fervent need to believe this. But news flash, a lot of really good people get STIs. Shit happens sometimes. That is life. But getting an STI doesn't make someone dirty or any of the other value judgments that people make. It just makes them unlucky, period.
So back to this clean partner thing. There are two things at work here. One is the use of clean to mean "disease-free." I take some exception to that since none of us are "disease-free." We've all had some nastiness infect us at one time or another: chickenpox virus and HSV-1 are among the infections that still remain in our bodies to this day.
But we all know that when we speak of the cleanliness of sexual partners, we are not worried about a partner's being infected with chickenpox. We are referring to STIs. People want their sexual partners to be clean, i.e. free from STIs. The converse of this is that people who have been infected with STIs are then dirty, or at the very least, unclean. And let us not pretend that the clean/unclean dichotomy is solely about uninfected/infected. We must admit that saying someone is clean implies more than just uninfected. It is a statement that reflects on their character. By the same dint, saying that someone is unclean, or God-forbid, dirty, implies much more than being infected with an STI. It implies that the person is of low moral character. This is the second process at work in the question of whether a partner is in fact, clean.
Since I've been working in the HPV arena, I can tell you that people always freak out when I give them the facts about HPV. The long story short is that if you have had unprotected sex with someone who has had unprotected sex with someone else, you have no doubt been infected with one of the 30-40 types of genital HPV. HPV is the common cold of STIs. After explaining this, the first thought that goes through people's heads is, "Hey, I could be infected. I could be dirty!" That is what happens when we have set up the construct that we are the clean and those nasty others (not to be confused with the "Others" from Lost) are the dirty. Suddenly STIs seem much more egalitarian.
The reason you haven't heard much about this is because you don't get tested for HPV as you do for gonorrhea and chlamydia. HPV testing is only run if you are over 30 and you have an abnormal PAP. (It can be run if you are under 30 and your pap is abnormal, but it isn't a screening test to see if it is in your body. The current HPV test is designed to help determine how aggressively your pap abnormality should be treated. If you have a high risk type, the treatment is more aggressive. Low risk: less aggressive.) It is not run as a screening test on those under 30 because it would be positive too often. New partner? New HPV strain. For the vast majority of people (90%)2, your body fights off the active infection within 2 years and that's about it. Yet those who have persistent HPV infection, especially with types 16 & 18, are at risk for the development of cervical and vaginal cancers and precancers. Men are also at risk for the development of penile and anal cancers, though penile cancer occurs at 1/10th of the rate of cervical cancer. And let's not forget our good friend the genital wart, also caused by HPV (low-risk types).
So how many people have been infected with HPV at some point in their lives? Well one study showed that by age 50, 80% of women have been infected with at least one type of HPV.3 And this is believed to be an underestimation based on limitations of the testing modality. So that makes a whole hell of a lot of us unclean or dirty.
And what about good ol' genital herpes? Studies estimate that the prevalence of genital herpes in the US adult population is 25%4 And remember that not everyone with herpes gets visible outbreaks. It's estimated that only 10-25% of people with positive antibodies for HSV-2 are aware that they are infected.4
Take women who get outbreaks on their cervices. I don't know about you, but I have no ability to see my own cervix. There could be a freaking viral conga line going on and there's no way I would know it. Sure if I were lucky enough to go to the gynecologist at the exact time that I might be having an outbreak, there would be an a-ha! And a few of my patients were diagnosed that way. But herpes on the cervix isn't painful and has no symptoms, so it can be there and no one knows. And again, there isn't a routine screening test for it.
So what's the point of this screed? To illustrate that with sex there is rarely an ability to separate the saintly clean from the disgustingly dirty. Even virgins can get STIs from skin to skin contact without anything going in somewhere.
Do I make this point to freak you out? (As this information generally freaked out my teen patients.) Of course not. My goal is to get away from the clean/dirty dynamic with regard to thinking about sexual partners. Sex, like anything else in life, is a risk. When we drive in a car there is always a risk that we could die. We try to take every safety precaution that we can: airbags, seatbelts, and not getting into broken down beaters driven by 5 year olds, but despite all those precautions, shit could still happen and we could die.
With sex, we can and should do as much as we can to reduce our risk: outercourse, condoms, no sex while impaired with substances, reduce hookups, etc. But no matter what, there will still be risk. Remember what I said before: sex is a calculated risk. You've got to decide who's worth rolling the dice for and despite all good intentions and precautions, you still might just crap out.
So let's put the clean/dirty value judgments aside and do better in understanding our STI risks and put them in perspective. Be aware, be as safe as you deem necessary, and have lots of fun.
That's teendoc's prescription.
References
Multiple Sexual Partners Among U.S. Adolescents and Young Adults. John S. Santelli, Nancy D. Brener, Richard Lowry, Amita Bhatt and Laurie S. Zabin. Family Planning Perspectives, Vol. 30, No. 6 (Nov. - Dec., 1998), pp. 271-275
- Epidemiology of acquisition and clearance of cervical human papillomavirus infection in women from a high-risk area for cervical cancer. Franco EL, Villa LL, Sobrinho JP, Prado JM, Rousseau MC, Désy M, Rohan TE. J Infect Dis. 1999 Nov;180(5):1415-23
Centers for Disease Control and Prevention (CDC) Genital HPV infection fact sheet. http://www.cdc.gov/std/HPV/STDFact-HPV.htm. Accessed August 12, 2008.
Genital Herpes. Rachna Gupta MD, Terri Warren ANP and Prof Anna Wald MD. The Lancet. Volume 370, Issue 9605, 22 December 2007-4 January 2008, Pages 2127-2137
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Comments
Silly example or spot on? "Clean" indeed. Show me a clean 16 year old male and I'll sell you some swamp land in Florida.
rated
Signed,
Oh, What a Ho
nn2r
thanks.
Teendoc, this is an excellant and NEEDED post!
Rated!
And god, I must be one monumental ho.
Seriously, informative and necessary post.
I do have a question. According to my OB/GYN, I was tested for HPV and came back negative yet you say there is not definitive test. ???
what I would have given to have this kind of info passed along by such a caring doctor when I was young and ---shall we say---more freelance.
great post doc. thank you.
Thanks everyone. It's bothered me for ages that so many teens (and grown folk) don't understand their risks for STIs. Even worse is when pediatricians/FPs/GYNs decide that their patients aren't at risk for STIs because they are: clean, innocent, wealthy, safe or whatever. Sure the more partners you have, the greater the odds are that you will come in contact with an STI, but having one or no partners does not mean that you have STI repellent either.
Hyblaean: Testing for HPV in males is not even possible outside of the research setting at this point...and even that involves abrading the penis with emery paper (don't you want your penis abraded?) and sending the abraded epithelium for PCR testing. As such, there's this big feeling of "wasn't me" since guys don't really understand that with HPV, there is generally no visible sign of infection with the high risk types and no testing to prove that you do or do not have it. It's easier to just say, "wasn't me." Sorry you had to go through that.
Greg: Let's not just demonize the boys here. Yes there is the testosterone driven I'll do anything with a pulse effect that is often at work, but the teen girl is becoming increasingly sexually aggressive as well. I had to hide one of my 13 year old male patients because some 12 year old chicklet in the waiting room was giving him a vivid description of what she wanted to do to him. And all he wanted to do was get back to his Playstation. Sheesh! So the faux clean cuts across both genders. (Also, too many STIs have no symptoms whatsoever, so the girl in your example many not even have a clue that she had an STI until she developed pelvic inflammatory disease, an abnormal PAP, or something worse.)
Ann: The over 60 crowd is a new demographic developing STIs. New partners bring new risk. Sorry about your mom.
Verbal and Liz: I think I may just have out-ho'ed you both. My accursed slut phase does me in every time. And oh yeah, I owe Black Bart the tale of my accidental sex episode...
Pretend: The HPV test currently done tests for 18 of the 30-40 genital HPV types (13 high risk and 5 low risk). So a negative test means that at the time you were tested you were negative for the 18 types in that panel. This says nothing about positivity to the other genital HPV types. Also, this testing does not speak about past infection...only current infection. So this testing will not give you an indication if you had been infected with HPV in the past and the infection cleared (or became dormant). Does this make sense?
Again, everyone, I'm so glad you found this post to be helpful. If there are more questions, just ask.
I think you're wrong about abandoning the sexual dichotomy, though. I mean, clearly Arthur Dimmesdale is a cleanly and upstanding man of God, and that Hester Prynne is a dirty, skanky 'ho. ;-)
(I was going to rate this post, but on second thought, I don't want to give you any of my man-slut germs)
rated
WOOF
Incidentally, my first reading of "no impaired sex" was, uh, damaged sex or impaired function sex or sex act not quite up to snuff... rather than 'no sex while impaired'. I'm obtuse like that! lol
You probably already know this, but probably the worst offenders of the phrase 'I'm clean' (as in 'STI free') may be found on those dating sites where people look for 'intimate contact' with others.
mah: we posted at the same time. As I said to Verbal and Liz, I'm sure if there was an arbiter for ho-ness, s/he would give me the unfortunate prize, as it were. I did wake up to the importance of connecting sex with love and tried to convey to my teen patients that if orgasm without intimacy is all you're after, sometimes the palm sisters are a better and safer avenue.
Grif: Please feel free to forward, steal (with attribution), Digg, Stumble, or anything else you think appropriate. I think the message needs to get out there. I might actually re-post this in my main blog (this is adapted from something I wrote there in 2006).
FatDavid: Aw, go ahead and rate me. I want this to stay on the feed. And from one ho to another, we've probably seen the same STIs, right? ;-) But this virtual contact is the safest sex ever...not that we're having sex, but you get my drift.
CCC: Play the game with your young adult: "Hey, I saw this post on OS that told me stuff that I didn't realize. I know you know the deal about this, but gee, why didn't you tell me some of this stuff?" Plays right into their loving the idea of knowing more than you do. I am wicked!
Cynarra: I should edit that phrase. I'm a better writer than that. Forgive the confusion.
OK, off to take the kiddo to Gymboree!
I generally avoid commenting on the medical posts because I don't even try to act like I'm intelligent enough to fully grasp what's going on.
But I like to think I know a little bit about sex.
I actually had to do a bit of research on STIs for someone who shall remain nameless so he doesn't kill me. And I found a lot of these statistics and my jaw hit the floor. It hit the floor again today when I saw your percentages on HPV.
In the still somewhat puritanical society we live in it's easy to see why we attach 'dirty and clean' in a description of one's sex life. It's just another way we can feel better about ourselves for something that we may have just been lucky on. It also makes people feel that they have control over the situation.
"John couldn't possibly have anything. I know he's clean."
You can delude yourself all you want into not facing the fact that John doesn't need to wear a condom because of your superior judgment. Everyone knows in the end it's a crap shoot. But if John gives sally the herp she can feel victimized and mislead by his cleanliness.
You'll have to pardon my french but the mind fuck's we allow ourselves in all areas of life show just how creative the human race is.
Anyway, this was a great post and one that most definitely needed to be made. Thank you so much for enlightening us, Doc.
And I do believe this is the longest comment I've ever made. Makes sense that in reference to sex.
Rated.
One problem about the clean/dirty issue is that it tends to promote lying.
I had a situation years ago that lasted awhile where I had common occasion to get dragged along to meetings of a young christian organization (let's call it CO, though this is a made-up name), and it was pretty clear to me that there were a lot of people leading dual lives (based on my appraisal of what they said at the meetings and what I knew of them in other venues, so not really scientific data—just my personal impression): a public persona that was clean and proper and a private one that didn't match up in various ways. They didn't want to lie about it, but felt they couldn't (sorry about the unfortunate double pun) come clean about it. I think at some level the people in the community felt, but could not articulate, that there was an immorality or inappropriateness or something about the organization being that nosey, but in any case they would have been quickly and harshly judged if they said how their real lives were. And I think this led to a sense that they were being forced to say the things they did at CO and so didn't in their minds after a while even regard them as lies so much as aspirations or their "true selve" or other kinds of ways of deluding themselves into thinking they weren't as they were. I don't say this to be harsh about them; I personally didn't judge them badly as I tended to agree with this notion, that it wasn't CO's business. But it seemed to me a kind of mandated hypocrisy at best and mostly an opportunity to hear things that were not true. I mention it here not to criticize, therefore, but merely to say that clinical infections are not going to tolerate vagueness on this subject, but rather are going to capitalize on it. This makes the question of religion as a good filter especially suspect.
Also, when you talk about sleep around, the lack of precision of terminology is an issue. Say words that are clinically accurate: have touched various specific intimate locations in any way, have had exposure to bodily fluids in various ways, etc. I am being vague here only for conversational politeness but partners need to be a lot more explicit than I'm being. "Sleeping around" might yield a "no" if the partner hadn't done it much, even though disease can spread on a single contact. Sleeping around might include sex but not sleeping for some people. Or might omit oral or other exotic forms of contact. Some people even delude themselves by saying it doesn't count if there was no love, or if they were just trying it, or if they decided later it was a mistake, or if there was no orgasm (irrelevant to most transmitted disease, I suspect, so a big red herring), or if penetration was only partial, or any of a number of reasons that will not impress living microorganisms.
Even virginity, which is classically a higher bar than sleeping around, has gigantic gaps in its terminology, since all the same issues apply.
And, finally, clean/dirty is an invitation to people who really care about each other to blame one another badly in cases where there may not be blame to be had. For example, suppose person A slept with 3 people and person B slept with 30. And then suppose that the two get infected with something. It may be that after some investigative work that A was the carrier. Referring to that person as dirty rather than both people as "at risk" makes for bad conversation. The issue is not just prevention. Good relationships can get broken by people pointing fingers instead of being supportive, and the specific terminology of clean/dirty can, well, dirty the conversation in a bad way that may be detrimental in emotional/social ways.
What a buzz kill. You must be a lot of fun at parties. Just teasing of course.
Wow, What a great deal of information.
I especially appreciate the fact that despite a superior intellect you write in everyday language that makes me never want to get laid again.
I've read about quite a bit of this stuff, but I read a great deal compared to the average American, as I'm sure most at this site do.
All this should be common knowledge to the masses and I'd guess to say that the percentage of the informed is very small.
In the meantime we get hammered day and night for erection pills and make your dick bigger infomercials. Man this world can be upside down. What a mess we humans are.
This is a true hormone killer if there ever was one. Maybe know I can stop thinking about sex and do the dishes. (as if)
Thanks for the post!
Anyway, my comments will be all over the map because of all the unrelated synopses this post generated: Bad Post ! Down! Down!
First as to the use of clean and dirty as moral terms. You can thank the Bible for a lot of the early discussions of those words in moral context.
There were elaborate sets of instructions that arose in Judaic law based on the Levitical laws that followed the Ten Commandments, detailed laws of how to live based on the broad principles of the Decalogue. Thus some foods were clean and others were "unclean," ditto for some normal bodily functions, some forms of social and sexual intercourse, etc. Unclean is an interesting English translation of the word we sometimes call dirty, because the Hebrew word does not mean "dirty" in a physical sense, but actually means contrary to the moral law.
But common usage has allowed lay Christians to think that unclean is a synonym for dirty. In any case the lists are long and many details are absurd, but many of them were actually based on the medical knowledge at the time. It is a fascinating little segment of Old Testament study that is too byzantine to go into here.
As for people in the church being more dirty than those who aren't in the church, it is simply a myth. Study after study indicate that there is no statistically significant difference between the actual actions of church goers and non church goers within otherwise comparable demographics.
Unfortunately, myths die harder than do facts and some parents are shocked, shocked! I tell you, to find out that little Sally and Billy have been playing doctor and went too far.
Witness the spectacle of the Palin girl. How a parent could put those kids through that public spectacle, or use her disabled baby ..................nevermind. But it does make the painful and unnecessarily ignorant point wherein we find that Mr. and Mrs Clean Alaskan Church Goer end up with a little 'Uh Oh!" right there is charming Wasilla.
Third, ignorance, even among medical professionals, is rampant and has been for years. When I was working in the Executive Office of the President, around 1966, I started getting some flaking lesions on my glans and went to an alleged uroligist to the powers that be of Washington. At that time I was married to my first wife.
After a very cursory exam, the heavily German accented, gray haired doc had me wait in his office and came in and looking profound, (think of Henry Kissinger in a lab coat) sat behind his huge walnut desk and declared in barely discernible English: "You have a sexually transmitted disease and will have to take a steroid and use a cream I will prescribe."
I asked how that could be possible because I had been with no one in my life but my wife, we had three kids together and were both exclusive partners and had been from the beginning. So he puffs up to look like an even bigger fish and says, "Then your wife is cheating on you!"
I won't go into the pain that caused me and my marriage. We divorced years later for totally unrelated reasons, but the doubt was always in the back of my head.
I learned decades later from a dermatologist that the problem, which I have now and then, is just one of several manifestations of my psoriasis that I have had all my adult life. Who knew? I sure as hell didn't. I didn't even know I had psoriasis even though I knew I had all the problems that, when showed to a competent doc much later in my life, had him conclude that I had it and should see a dermatologist.
Finally, totally off the wall, this discussion of clean and dirty reminded me that it isn't even that easy to dissect. My mother insisted that there was a difference between "clean dirt" and "dirty dirt." She would tolerate it if I got into the former but kill me if I got into the latter. Gotta love that distinction.
Important post. Much appreciated, in spite of my rambling response. Rated.
Monte
Do I even need to touch this one? I don't think so.
Haha, this is funny. Church is the easiest place to score if you don't mind the pastah's rejects.
Very informative post.
BTW, can I interest you in aPURVIS 2,1/2 ?
I am sooo glad to see posts like this one. I got three kids. One had genital warts. She claims to 'know' which boy gave it to her. Yeah, right.
I am a ho fer sure. A very dirty one. This makes me smile.
I have often heard people talk about sleeping around with 'clean folks', and don't worry, h/s has been tested and is 'clean'. Now I am laughing. The subject is not funny.
I can tell you care about this passionately. I appreciate this.
Thanks so much!
Thomas, you're asleep at the frickin' switch! This post deserves an Editor's Pick and a cover spot. It is MUCH more informative than the .... ah.... "medical" post that is currently up there.
Thumbed.
A number of you have mentioned being a little scared by the information. But the truth of the matter is life is risky and we must take some leaps in order to experience some joys. Yet if we are deciding to have unprotected sex with that person only because s/he's hot, perhaps we might just engage the Palm Sisters instead since that might not be a risk worth taking. What I'm saying is that we should try to be sensible and not scared, since scared doesn't lead to good judgment (at least not in adolescents).
And Mary and Bill: I would love to see this post get more exposure, not just because of being a blogwhore (smile), but because I think the information is important. I'm not sure why it didn't meet criteria for EP or even Most Read or Rated, but I'm so glad you guys came, read and commented.
Thanks!
hopefully this will help narrowminded people and teach everyone else that you should always becareful.. but remember that it could still happen to you..