Sex, Gender and Sexuality: Sexually Transmitted Diseases

Sexually transmitted infections are common and in most instances preventable. Bacterial infections like chlamydia, gonorrhea, and syphilis are discussed below as are the Herpes Simplex Viruses, the human papillomavirus, and the human immunodeficiency virus. Descriptions of symptoms, treatments, current rates of infection, and populations affected are provided. The controversy surrounding the newly recommended vaccination against the human papillomavirus (HPV) is also discussed as is the societal need to combine efforts at prevent infections.

Keywords Acquired Immunodeficiency Syndrome (AIDS); Chlamydia; Gonorrhea; Herpes Simplex Viruses; Human Immunodeficiency Virus (HIV); Human Papillomavirus (HPV); Sexuality; Sexually Transmitted Diseases; Sexually Transmitted Infections; Syphilis

Sexually Transmitted Diseases

Overview

Sex is presented in magazines and other media as something everyone should be doing. Teenagers giggle about it; their parents are embarrassed by it, and various cultures treat it like a gift. Underneath the emotion and exhilaration of sexuality hides a reality unique only to sexual activity itself. According to the World Health Organization in 2013 there are 499 million new curable sexually transmitted infections (like syphilis, gonorrhoea, chlamydia and trichomoniasis) every year. That these cases are curable means that with a timely diagnosis and proper treatment, these infections can be eradicated. Those that are not diagnosed early or treated properly make up an entirely different statistic.

Sexually transmitted infections (STIs) can be spread from person to person through anal, oral, or vaginal intercourse or passed from mother to child during pregnancy or delivery. STIs come in the form of bacteria, parasites, or viruses, with the latter remaining in its host indefinitely. While most bacterial forms of STIs (chlamydia, gonorrhea, and syphilis) can be eliminated with a dose of an antibiotic, the lasting effects of an untreated infection can cause pelvic inflammatory disease, infertility, and more serious conditions for infants born to infected mothers. The viral forms of STIs include the human papillomavirus, herpes simplex virus, and human immunodeficiency virus (HIV), which causes the severe complications noted in acquired immunodeficiency syndrome (AIDS). There are antiviral medications that can decrease the effects of viral outbreaks, shortening symptoms and lessoning the number of outbreaks, but there is no cure for the viruses acquired through sexual intercourse.

Many people become infected and never know it. As a result, infections are transmitted without the knowledge of either partner, and those infections do damage in hiding. For most people, however, the symptoms of an STI are acute and obvious. For example, many infected individuals note an unusual discharge, sores known as ulcers on the affected area, genital or lymph node swelling, and pelvic pain. In some cases, fever and cold-like symptoms also appear. Some people experience symptoms right away while others may not note symptoms for weeks, sometimes years, after initial infection.

The only way to avoid acquiring a sexually transmitted infection is to abstain from all types of sexual intercourse or to have monogamous intercourse with an uninfected partner. Male latex condoms are an effective way to avoid an infection (when used consistently and correctly), but they do not guarantee safety, as a condom may not fully cover an affected area.

Prevalence

In 2013 the US Centers for Disease Control and Prevention reported that there are 20 million new STIs annually, with a total of 100 million across the country. The most common STIs are chlamydia, gonorrhea, hepatitis B virus, herpes simplex virus type 2, HIV, human papillomavirus (HPV), syphilis, and trichomoniasis. For example, in the world's poorest countries, where access to condoms, screening, and treatment are limited (or nonexistent), unsafe sex ranks second only to being underweight for causing the population's disease, disability, or death rates (p. 1597). It should be noted that unsafe water and sanitation are ranked third. When one's water supply poses less of a health risk than having sex, the importance of the problem should be clear.

Further Insights

The Common Infections

Chlamydia

Chlamydia is the most commonly reported sexually transmitted infection, with almost three million Americans infected with it each year. It is probable that this statistic is inaccurate as many people who suffer from the bacterial infection do not appear or feel symptomatic, and therefore, do not get screened for it. If diagnosed early, an antibiotic can clear the infection; if the infection remains undetected, however, Chlamydia can cause infertility in both men and women. It can also cause swelling in the prostate and painful urination in men. In women, the infection can cause pelvic inflammatory disease, chronic pain during intercourse and/or urination, and it can cause eye infections and pneumonia in babies through mother to infant transmission during pregnancy or delivery.

As young adults between the ages of fifteen and twenty-four are the most prolific population to acquire the infection, it is recommended that anyone under the age of twenty-five have a yearly screen as well. In addition, anyone who is pregnant or who is sexually active and experiences pain during intercourse or urination or has an abnormal discharge should be screened as well ("Common STD Risky," 2008).

Human Papillomavirus (HPV)

The human papillomavirus (HPV) is the most common STI in the United States and there is no treatment for it. Once infected with HPV, a person’s immune system will clear most HPV within two years, while the disease can still persist in some cases. There are over ten types of high-risk forms of HPV, with types HPV-16 and HPV-18 causing the majority of HPV-caused cancers; most high-risk forms of HPV will not cause cancer. HPV is sexually transmitted through anal, oral, and vaginal intercourse, and it is important to note that no sexual activity is less risky than another.

There is an FDA-approved vaccination for the HPV-16 and HPV-18 viruses. However, as with all vaccines, Gardasil and Cervarix (the brand names of two vaccines) brought some controversy. First, Gardasil was approved for young women, not young men. Therefore, while young women can become vaccinated for the HPV-16 and HPV-18 strains, men cannot, which leaves an entire population of people without protection. Second, the vaccine is recommended for young women prior to becoming sexually active. This means that to be effective, the vaccine should be administered prior to girls becoming teenagers, generally between their tenth and twelfth years. This recommendation comes from the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, and the American Academy of Family Physicians (Iannelli, 2007).

As with most vaccines, a recommendation is not the same as a requirement. In addition, while requiring the vaccine would ensure that young women become protected from cervical cancer, many people could argue that having any defense from a sexually transmitted disease forced upon them is an unconscionable way to offer that protection.

In 2007 it was reported that 47 percent of high school students report having had sexual intercourse, and 34 percent of sexually active students said that they didn't use a condom the last time they had; the CDC also reported that over 14 percent of women who were 18 to 25 with only one lifetime sex partner still had HPV infections (Ianelli, 2007, "Necessity").

In other words, about one in eight young women who have sexual intercourse only once with only one person will still develop an HPV infection; this statistic includes young women who only have oral sex as well. In the chance that HPV develops into cancer, it is possible that someone infected at the age of fifteen would not develop cervical cancer until much later in her life. Yearly gynecological exams (including pap smears) can detect the abnormal cells related to cervical cancer, and early steps like biopsies and excisional procedures (Clifford, Smith, Aguado & Franceschi, 2003, as cited in Cox et al., p. 856) can be taken to halt the development of cancer, but until all young women have easy access to yearly exams and post-diagnosis procedures, the vaccine may be the best option.

Gonorrhea

Much like Chlamydia, Gonorrhea is a bacterial infection that can be treated with an antibiotic. In contrast to the former infection, however, the latter is showing resistance to many antibiotic treatments, making it a potential health hazard in America. According to the CDC in 2012, 820,000 Americans get new gonorrheal infections annually. Gonorrhea can cause no symptoms, making its detection difficult in many cases. When diagnosed, it is usually because symptoms like inflammation in the genitals and reproductive organs, painful urination, or unusual discharge from the vagina or penis are noted (Gonorrhea - CDC Fact Sheet). The infection can be transmitted to infants from their mothers, can cause infertility, and can spread to the blood and joints. In addition, gonorrhea infection raises the risk of acquiring the human immunodeficiency virus (HIV) for anyone who is sexually active (Gonorrhea - CDC Fact Sheet).

Statistically, gonorrhea rates in the United States indicate a higher prevalence in African Americans (than in whites) and in women more than men (CDC Surveillance, 2006). Various antimicrobials (antibiotics) have been used against the gonorrhea bacteria. However, since the early 1930s, the bacteria has changed enough to become resistant to several of these remedies, including Penicillin and other sulfa drugs (Workowski, Berman & Douglas, 2008, p. 606). The regime of cephalosporin treatment works effectively and efficiently; however, as many drugs that have been used in the past fall victim to a stronger bacteria, it is necessary that other options be explored in case resistance occurs for cephalosporin as well (Workowski, Berman & Douglas, 2008, p. 609).

Persons with identifiable risk factors should be screened for gonorrhea, as early detection is the best way to prevent complications from the infection, which decreases the possibility of medicinal resistance. According to the United States Preventive Task Force, women who are pregnant, are younger than 25, who have had a previous gonorrhea or other STD/STI, who have had multiple sex partners, who have used condoms inconsistently, who use drugs, and who are are commercial sex workers should be tested for gonorrhea (U.S. Preventive Services Task Force, 2005). In addition, men who have sex with men should also be tested, especially those with HIV (CDC: CDC: Updated Recommendations). Likewise, anyone in these risk categories should be screened for all other STIs and STDs as well (CDC: Updated Recommendations).

Herpes Simplex Virus

According to Associate Professor of Nursing, Janelle Gardner (2006), the "strongest predictor" of genital herpes is "multiple sexual partners" (p. 26). In other words, contracting the herpes simplex virus (HSV) can be predicted based on whether or not a person has more than one sexual partner in his or her lifetime. Having sex with only one person is risky; that risk increases with every additional sex partner because each new person brings in a risk from someone else, and the numbers multiply quickly, whether the intercourse is oral, anal, or vaginal across partners. By 2013 approximately 776,000 Americans get new herpes infections annually—with approximately 16 percent, of one out of six, of people between the ages of 14 to 49 affected.

Gardner also notes that while some people will become infected with the virus and only have one initial outbreak of symptoms "about 90% of those infected have at least one recurrence during the first year and most have multiple recurrences-6 to 12 outbreaks per year on average" (p. 46); the World Health Organization (WHO) cites 4-5 recurrences as average (Herpes Simplex Type 2). Like other viruses, HSV is incurable. There are antiviral medications that hinder the length of an outbreak and lessen the severity of the symptoms, but the virus remains in its host indefinitely.

In addition, HSV causes a risk of encephalitis to infants born to mothers who carry the virus (Herpes Simplex Type 2), and it poses a constant risk of transmission through sexual activity, even if a condom is used correctly, as the condom may not completely cover all of the HSV infected areas (Gardner, p. 27). According to WHO, "the same independent factors of HSV-2 infection were identified in both genders: older age [between 30-40], higher lifetime number of sexual partners, positive HIV serology and positive syphilis serology" (Herpes Simplex Type 2). WHO also notes that there is "ample evidence that HSV-2 infection is a major cofactor of HIV infection" (Herpes Simplex Type 2). In other words, "people infected with HSV-2 are at increased risk of acquiring HIV" (HIV/AIDS and STD Updates, 2008).

Human Immunodeficiency Virus (HIV) & AIDS

By 2013 HIV/AIDS remained fourth biggest killer globally. Again, in areas where access to condoms and effective treatment is limited, people are going to suffer the consequences of their economic disadvantage. HIV is not just an issue in underdeveloped countries, however. According to the New York City Department of Health and Mental Hygiene in 2009, almost one in five NYC adults are at risk for contracting HIV due to having multiple sex partners, inconsistently using condoms, or because of they use injected drugs; yet, more than ninety percent of the people involved in the survey (who fell into those categories) indicated that they believed they were not at risk (HIV/AIDS and STD Updates, p. 259).

AIDS is the final stage of the HIV infection, which was first identified in the U.S. in 1981. Within a ten-year period the virus was studied, and measures to treat complications from the virus were created, reducing the death rates from AIDS by more than thirty percent annually. The CDC estimates that one million people are infected with the HIV virus, with one in four of those people not knowing they have the infection (Centers for Disease Control and Prevention, 2007a). HIV is only found in bodily fluids - blood, semen, vaginal excretions - and can be transmitted by having anal, oral, or vaginal intercourse, sharing needles with an infected person, or via mother to infant transmission during pregnancy, delivery, or breastfeeding. While previous cases have been identified of people acquiring HIV from blood transfusions, blood donations have been screened for the virus since 1985 (Centers for Disease Control and Prevention, 2007a).

The only way to know for sure if HIV is present in someone is for that person to be tested. There are currently over-the-counter tests available in most pharmacies, and most doctor's offices, health care clinics, and Planned Parenthood offices provide testing as well. Anyone who has already had an STI diagnosis is at greater risk of acquiring HIV than someone who has not had a sexually transmitted infection. Also, the CDC notes that anyone "receiving a blood transfusion or clotting factor during 1978-1985," anyone who has shared injection materials (needles, syringes, etc.) with someone who is HIV positive, anyone who has had anal, oral, or vaginal sex without using a condom, or someone who has exchanged sex for drugs or money is also at risk for HIV infection (Centers for Disease Control and Prevention, 2007a).

Syphilis

In 1999, a campaign was established to eradicate syphilis. The National Plan to Eliminate Syphilis combined the efforts of the CDC with federal, state, local, and non-governmental agencies to expand responses to an outbreak, increase screening and treatment of those infected, expand lab services, and enhance the promotion of healthy sex practices (Centers for Disease Control and Prevention, 2007b). For the most part, the plan worked. However, the demographic of people with syphilis has changed, and so has the response. Currently, more than half of new syphilis infections are diagnosed in men who have male sex partners. As such, problematic social issues have made it difficult to identify and treat those infected. "The social contexts of poverty, racism, homophobia, and socio-economic discrimination continue to drive the concentration of the disease in those with high-risk sexual behaviors, poor access to care, or both" (Centers for Disease Control and Prevention, 2007b, par. 3).

While the demographics have changed, the signs and symptoms have not. There are three distinct stages to a syphilis infection. A primary infection is noted by the appearance of one or multiple sores possibly ten to ninety days following infection. If treatment is not provided, secondary syphilis presents a rash that does not itch. Additional symptoms include fatigue, fever, headache, sore throat, swollen lymph glands, and patchy hair. Again, secondary symptoms will resolve without treatment but carry a risk of latent infection if not treated (Centers for Disease Control and Prevention, 2008b).

Latent syphilis infection can appear ten to twenty years after infection was first transmitted. About 15% of people who are not treated in the early stages of syphilis will develop this life-threatening illness and can transmit the infection never knowing they are ill. Latent syphilis causes damage to internal organs including the heart, the liver, the eyes, nerves, blood vessels, joints, and the brain - people actually become mentally ill because of this disease. The deterioration in health is marked by coordination problems, gradual blindness, numbness, paralysis, and dementia. In some cases, irreversible damage is severe enough to cause death (Centers for Disease Control and Prevention, 2008b).

Viewpoints

Global Prevention Program Required

Hook and Leone (2006) offer suggestions for controlling the spread of Herpes Simplex Virus:

We believe that available tools (serological testing, condom promotion, long-term suppressive antiviral therapy, and disclosure of infection status to sex partners) provide the means for developing a comprehensive national program to control the spread of genital herpes (Hook & Leone, 2006, p. 7).

In addition to Hook and Leone's (2006) view and the CDC's effort to thwart syphilis it seems likely that all sexually transmitted infections could one day be as insignificant as the common cold. That day is a long way away, though. With young people being the most at risk, making that population understand the severity of this problem is just one way to step toward an improvement in statistics.

To diminish certain health problems, developed societies created laws to ban smoking, to admonish drunk driving, and to promote healthy eating. These same societies even integrate sex education in many school systems to deter teenage pregnancy. Yet, these same societies do not band together to encourage safer sex practices for the health of its future; a task as easy as purchasing media time, encouraging family discussions, and requiring yearly screenings. This is the case with regard to sexually transmitted infections. If global activism embraced the issues surrounding sexually transmitted infections the way it has with smoking and recycling, transmission could be controlled in less than a decade.

Terms & Concepts

Acquired Immunodeficiency Disease (AIDS): Various conditions (and often, diseases) caused by complications from the human immunodeficiency virus (HIV).

Chlamydia: A bacterial infection acquired through various sexual contact (oral, anal, and penile/vaginal intercourse), often producing no symptoms but causing serious effects (like infertility and chronic pain) if left untreated.

Gonorrhea: A bacterial infection acquired through sexual contact such as oral, anal, and vaginal intercourse; generally causes inflammation and pain during urination.

Herpes Simplex Viruses (HSV): A viral infection spread through sexual contact (such as oral, anal, and vaginal intercourse) that causes small blisters and swelling where mucous membranes and skin tissue connect in the nose, genitals, or mouth.

Human Immunodeficiency Virus (HIV): A retrovirus passed through body fluids (semen, blood, vaginal secretions) which destroys immune system defenses.

Human Papillomavirus (HPV): A retrovirus that is spread through sexual intercourse that can cause genital warts, cervical cancer, and throat cancers.

Sexuality: Being involved in or interested by sexual activity; sexual orientation.

Sexually Transmitted Diseases: Signs and symptoms of infections acquired through sexual contact (i.e.: symptoms of AIDS (nausea, fatigue, suppressed immune system, are caused by HIV).

Sexually Transmitted Infection: A bacterial or viral infection that passes from one person to another through (oral, anal, or vaginal) sexual activity.

Syphilis: A bacterial infection passed by (anal, oral, or vaginal) sexual intercourse or from mother to child; can result in infections of the brain, the skin, nervous tissue, and genitalia.

Bibliography

Centers for Disease Control and Prevention. (2007a). HIV/AIDS: Basic Information. Retrieved July 18, 2008 from CDC website: http://www.cdc.gov/hiv/topics/basic/index.htm

Centers for Disease Control and Prevention. (2007b). Syphilis Elimination Effort (SEE): The National Plan to Eliminate Syphilis from the United States - Executive Summary. Retrieved July 17, 2008 from CDC website: http://www.cdc.gov/stopsyphilis/SEEexec2006.htm

Centers for Disease Control and Prevention. (2007c). Sexually Transmitted Disease Surveillance, 2006. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved July 16, 2008 from CDC website: http://www.cdc.gov/std/stats/default.htm

Centers for Disease Control and Prevention. (2007d). Updated recommended treatment regimens for gonococcal infections and associated conditions - United States, April 2007. Retrieved July 16, 2008 from CDC website: http://www.cdc.gov/std/treatment/2006/updated-regimens.htm

Centers for Disease Control and Prevention. (2008a). Sexually Transmitted Diseases: Gonorrhea - CDC Fact Sheet. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved July 16 from CDC website: http://www.cdc.gov/std/Gonorrhea/STDFact-gonorrhea.htm

Centers for Disease Control and Prevention. (2008b). Sexually Transmitted Diseases: Syphilis - CDC Fact Sheet. Atlanta, GA: U.S. Department of Health and Human Services. Retrieved July 16 from CDC website: http://www.cdc.gov/std/syphilis/STDFact-Syphilis.htm

CDC: One in four teens has an STI. (2008). Contemporary Sexuality, 42 , 11-12. Retrieved July 6, 2008 from EBSCO online database SocINDEX with full text: http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=31955105&site=ehost-live

Common STD risky to young and old. (2008). Consumer Reports on Health, 20 , 6. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31601888&site=ehost-live

Cox, J. T., Mahoney, M. C, Saslow, D. & Moscicki, A. (2008). ACS releases guidelines for HPV Vaccination. American Family Physician, 77 , 852-863.

Darrow, W. W. & Biersteker, S. (2008). Short-term impact evaluation of social marketing campaign to prevent syphilis among men who have sex with men. American Journal of Public Health, 98 , 337-343. Retrieved July 6, 2008 from EBSCO online database SocINDEX with Full Text: http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=30103033&site=ehost-live

Foster, L. R., & Byers, E. (2013). Stigmatization of individuals with sexually transmitted infections: effects of illness and observer characteristics. Journal Of Applied Social Psychology, 43E141–E152. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=87990618

Gardner, J. (2006). What you need to know about genital herpes. Nursing, 36 , 26-27. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=22489243&site=ehost-live

Glasier, A., Gulmezoglu, A. M., Schmid, G. P., Moreno, C. G. & Van Look, P. F. A. (2006). Sexual and reproductive health: A matter of life and death. Lancet, 368 (9547), 1595-1607. Retrieved July 14, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=22950231&site=ehost-live

Healy, B. (2008). Clueless about risks of oral sex. U.S. News & World Report, 144 , 60. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31173019&site=ehost-live

HIV/AIDS and STD Updates. (2008). AIDS Patient Care & STDs, 22 , 259-262. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31256783&site=ehost-live

Hook, E. W. & Leone, P. (2006). Time to translate new knowledge into practice: A call for a national genital herpes control program. Journal of Infectious Diseases, 194 , 6-7. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=21175381&site=ehost-live

Iannelli, V., M.D. (2007). HPV Controversy. About.com: Pediatrics. Retrieved July 11, 2008 from About.com: http://pediatrics.about.com/od/immunizations/a/0307_hpv_cntvsy.htm

Lepusic, D., & Radovic-Radovcic, S. (2013). Risk factors for sexually transmitted infections among young adolescents. Collegium Antropologicum, 37, 455–458. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=89603860

Rodriguez, H. P., Chen, J., Owusu-Edusei, K., Suh, A., & Bekemeier, B. (2012). Local public health systems and the incidence of sexually transmitted diseases. American Journal Of Public Health, 102, 1773–1781. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=79279163

U.S. Preventive Services Task Force. (2005). Screening for gonorrhea: recommendation statement. American Family Physicians, 72 . Retrieved July 16, 2008 from website: http://www.aafp.org/afp/20051101/us.html

World Health Organization. (2007). Sexually Transmitted Infections: Infections and transmission. Retrieved July 13, 2008 from WHO website: http://www.who.int/mediacentre/factsheets/fs110/en/index.html

World Health Organization. (2008). Sexually Transmitted Diseases: Herpes simplex type 2. Retrieved July 16, 2008 from WHO website: http://www.who.int/vaccine_research/diseases/soa_std/en/index3.html

World Health Organization. (2008). Sexually Transmitted Diseases: HIV/AIDS. Retrieved July 16, 2008 from WHO website: http://www.who.int/vaccine_research/diseases/soa_std/en/index4.html

Workowski, K., Berman, S. M. & Douglas, J. M. (2008). Emerging antimicrobial resistance in neisseria gonorrhoeae: Urgent need to strengthen prevention strategies. Annals of Internal Medicine, 14 , 606-W124 Retrieved July 9, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31703767&site=ehost-live

Suggested Reading

Abelson, M. B. & Leung, S. (2008). The many faces of chlamydial infection. Review of Ophthalmology, 15 , 84-87. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31697167&site=ehost-live

Adams, J., Moody, J., & Morris, M. (2013). Sex, drugs, and race: How behaviors differentially contribute to the sexually transmitted infection risk network structure. American Journal Of Public Health, 103, 322–329. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=84689875

Alan Guttmacher Institute. (1999). Sharing responsibility: Women, society & abortion. New York: Alan Guttmacher Institute.

Beauman , J. G. (2005). Genital herpes: A review. American Academy of Family Physicians, 72 , 1527-1534.

Brown, Z. A., Selke, S., Zeh, J., et al. (1997). The acquisition of herpes simplex virus during pregnancy. New England Journal of Medicine, 337, 509-15.

CDC. Youth Risk Behavior Surveillance-United States, 2005. (2006). CDC. Morbidity & Mortality Weekly Report, 55 , 108.

Centers for Disease Control and Prevention. (2003). Internet use and early syphilis infection among men who have sex with men-San Francisco, California, 1999-2003. MMWR Morbidity & Mortality Weekly Report, 52 , 1229-1232.

Clifford, G. M., Smith, J. S., Aguado, T. & Franceschi, S. (2003). Comparison of HPV type distribution in high-grade cervical lesions and cervical cancer: A meta-analysis.

British Journal of Cancer, 89 , 101-105. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=10152670&site=ehost-live

Corey, L., Wald, A., Patel, R., et al. (2004). Once daily valacyclovir to reduce the risk of transmission of genital herpes. New England Journal of Medicine, 350, 11-20.

Darville, T. (2005). Chlamydia trachomatis infections in neonates and young children. Seminars in Pediatric Infectious Diseases, 16 , p. 235-44.

Datta, S. D., Koutsky, L. A., Ratelle, S., Unger, E. R., Shlay, J., McClain, T., Weaver, B., Kerndt, P., Zenilman, J., Hagensee, M., Suhr, C. J. & Weinstock, H. (2008). Human papillomavirus infection and cervical cytology in women screened for cervical cancer in the United States, 2003-2005. Annals of Internal Medicine, 148 , 493-501. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=31637770&site=ehost-live

Doctors, Legislators Differ On HPV Vaccine Mandates. (2007). Pediatric News, 4 , 1.

Ezzati, M., Lopez, A. D., Rodgers, A., Vander Hoorn, S., Murray, C. J. L., and the Comparative Risk Assessment Collaborating Group. (2002). Selected major risk factors and global and regional burden of disease. Lancet, 360, 1347-60.

Fleming, D. T. & Wasserheit, J. N. (1999). From epidemiologic synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections, 75, 3-17.

Freeman, E. E., et al. (2006). Herpes simples virus 2 infection increases HIV acquisition in men and women: systematic review and meta-analysis of longitudinal studies. AIDS, 20 , 73-83.

FUTURE II Study Group. (2007). Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. New England Journal of Medicine, 356 , 1915-1927.

Gostin, L. O. & DeAngelis, C. D. (2007). Mandatory HPV Vaccination: Public Health vs Private Wealth. JAMA, 297, 1921-1923.

Harper, D. M., Franco, E. L., Wheeler, C., et al., for the Glaxo-SmithKline HPV Vaccine Study Group. (2004). Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet, 364 (9447), 1757-1765.

Kalayoglu, M. V. (2002). Ocular chlamydial infections: Pathogenesis and emerging treatment strategies. Current Drug Targets: Infectious Disorders, 2 (l), 85-91.

Klausner, J. D., Wolf, W., Fischer-Ponce, L., Zolt, I. & Kate, M. H. (2000). Tracing a syphilis outbreak through Cyberspace. JAMA, 284, 447-449.

McFarlane, M., Bull, S. S. & Rietmeijer, C. A. (2000). The internet as a newly emerging risk environment for sexually transmitted diseases. JAMA, 284, 443-446.

Owusu-Edusei Jr, K., Chesson, H. W., Leichliter, J. S., Kent, C. K., & Aral, S. O. (2013). The association between racial disparity in income and reported sexually transmitted infections. American Journal Of Public Health, 103, 910–916. Retrieved November 18, 2013 from EBSCO Online Database SocINDEX with Full Text. http://search.ebscohost.com/login.aspx?direct=true&db=sih&AN=86139469

Paavonen, J., Jenkins, D., Bosch, F. X., et al., for the HPV PATRICIA Study Group. (2007) Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial. Lancet, 369 (9580), 2161-2170.

Ross, J. A. & Winfrey, W. L. (2002). Unmet need for contraception in the developing world and the former Soviet Union: an updated estimate. International Family Planning Perspectives, 28 , 138-43. Retrieved July 6, 2008 from EBSCO online database Academic Search Complete: http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=7496980&site=ehost-live

RØttingen, J. A., Cameron, D.W. & Garnett, G. P. (2001). A systematic review of the epidemiologic interactions between classic sexually transmitted diseases and HIV: how much really is known? Sexually Transmitted Diseases 28 , 579-97.

Saslow, D., Runowicz, C. D., Solomon, D., et al. (2002). American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA: A Cancer Journal for Clinicians, 52 , 342-362.

Schiffman, M. & Castle, P. E. (2005). The promise of global cervical cancer prevention. New England Journal of Medicine, 353 , 2101-2104.

U.S. Preventive Services Task Force. (2005). Screening for genital herpes: Recommendations and rationale. American Family Physicians, 72, 1557-1561.

Wald, A., Langenberg, A. G., Link, K., et al. (2001). Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA, 285, 3100-6.

Weinstock, H., Berman, S. & Cates J. W. (2004). Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspectives on Sex and Reproductive Health, 36 , 6-10.

WHO. (2001). Global prevalence and incidence of selected curable sexually transmitted infections: Overview and estimates. Geneva: World Health Organization.

WHO. (2004). Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2000, (4th ed.). Fourth edition. Geneva: World Health Organization.

WHO. (2004). Maternal mortality in 2000: estimates developed by WHO, UNICEF and UNFPA. Geneva: World Health Organization.