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Sexually Transmitted Disease

The incidence of sexually transmitted diseases (STDs) in the United States is higher than any other country, with approximately 15 million new cases diagnosed each year. It is estimated that approximately two-thirds of these cases are represented by two diseases: trichomoniasis and human papilloma virus (HPV). Furthermore, an estimated 65 million people are living with an incurable STD. Sexually transmitted diseases include those produced by fungal, bacterial, and viral pathogens, as well as parasitic infection with pubic lice (commonly called 'crabs') and scabies (caused by mites). These diseases may produce symptoms ranging from mild to severe, and may result in simply a minor nuisance, or potentially be life-threatening if left untreated.

The incidence of STD's among people with intellectual disabilities is not well-documented. However, it should be assumed that people with intellectual disabilities who are sexually active are at similar risk as the general population. Furthermore, individuals with intellectual disabilities experience an increased risk of sexual abuse. Such abuse may expose them to sexually-transmitted pathogens, even when they are not voluntarily sexually active. Considering these factors, it is important to screen all women, including those with intellectual disabilities, for sexually transmitted disease during routine gynecological exams.

It is important that primary care providers be aware of the issues surrounding sexuality and sexual expression in persons with intellectual disabilities. See the Sexuality Education and Sexuality and Self-Determination resource documents for more information.

Some frequently encountered sexually transmitted diseases and their symptoms are outlined below. Symptoms for males are not included. This list is not exhaustive.

Chlamydia trachomatis is the most frequently reported bacterial STD in the United States. Infection with Chlamydia may potentially damage a woman's reproductive organs. Infection may be silent without significant symptoms; therefore, complications may occur before the problem is recognized. Symptoms, when present, include abnormal vaginal discharge, painful urination, lower abdominal pain, low back pain, nausea, fever, painful intercourse, and/or menstrual spotting. Chlamydia infections may spread to the throat or rectum. Chlamydia causes pelvic inflammatory disease in approximately 40% of women infected. Annual screening for all sexually active women is recommended. Chlamydia is easily treated with antibiotics such as a single dose of Azithromycin or a one week course of doxycycline. Sexual partners must also receive treatment in order to prevent re-infection.

Gonorrhea is a sexually transmitted disease caused by the bacterium Neisseria Gonorrhoeae. Gonorrhea reproduces easily in warm, moist, locations, including the vagina, rectum, cervix, uterus, fallopian tubes, urethra, mouth, throat, and eyes. Untreated gonorrhea may even spread to the blood or joints. Gonorrhea is very common in the United States. The Center for Disease Control estimates that approximately 700,000 new cases are diagnosed each year. Symptoms may be very mild or absent. When present, symptoms may include painful urination, increased vaginal discharge, and/or menstrual spotting. Oral infection may present as a sore throat. Gonorrhea is a common cause of pelvic inflammatory disease (PID) in women. PID typically presents with symptoms such as chronic lower abdominal pain, fever, internal abscesses, and scarring of the fallopian tubes. Gonorrhea is treated with a variety of antibiotics. Sexual partners should be identified and treated in order to prevent both patient re-infection and further spread of the disease within the community.

Genital Herpes is caused by the herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2), with the type 2 being responsible for the majority. Infection may be silent or may present with blisters in the genital and/or rectal area. Blisters typically progress to tender ulcers that may take up to four weeks to heal. Outbreaks may become chronic, with subsequent episodes typically becoming less severe. According to the CDC, approximately one out of four women has been infected with HSV-2. Herpes can be contracted by the infant during vaginal delivery where it may induce potentially fatal infection without intervention. There is no known cure for herpes; however, antiviral medications may help to prevent or shorten outbreaks only during the time the medication is being taken. Women should be educated about herpes infections, particularly concerning disease transmission. Latex condoms are not completely effective in preventing herpes infection as not all potentially affected areas are covered.

Genital HPV infection is a sexually transmitted disease caused by human papillomavirus (HPV). The CDC estimates that 20 million Americans are currently infected with HPV, with approximately 6.2 million new cases diagnosed annually. There are over 100 strains of HPV, with approximately 30 of these being sexually transmitted. HPV infection affects the female genital area including the vulva, anus, vaginal lining, cervix, and rectum. There is no medical 'cure' for HPV infection; however, most HPV infections produce little or no symptoms and clear up on their own. A few of the viruses are designated 'high-risk' types and have been implicated in abnormal Pap smears. Ten high risk types of HPV have been linked most significantly to the development of cervical cancer. Chronic, persistent infection with 'high-risk' HPV is the number one risk factor for cervical cancer. Genital warts are a manifestation of 'low-risk' HPV.

HIV (human immunodeficiency virus) is probably the most feared of all sexually transmitted diseases due to both to the severity of symptoms and terminal nature of disease progression. Infection with HIV causes Acquired Immune Deficiency Syndrome (AIDS). HIV is spread through contact with blood and/or body fluids, including sexual fluids and breast milk. HIV produces symptoms which reflect the individual's increased susceptibility to a variety of secondary infections. The inability to 'fight off' infection is in effect the eventual cause of death in persons experiencing full-blown AIDS. A person may test positive for HIV without experiencing AIDS. There is no known cure for HIV infection at the current time, although progress has been made in ameliorating the symptoms and slowing disease progression. Women should be educated in ways to protect themselves from HIV infection (as well as STDs in general) as part of routine gynecological care.

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It is often difficult to diagnose syphilis infections as the symptoms may mimic many other conditions. The disease presents in one of three stages. The primary stage is marked by the appearance of one or more chancre sores. The sore occurs at the location where the bacterium entered the body. Although the sores are typically painless and resolved in 3-6 weeks, the infection will progress to the secondary stage if left untreated. In the secondary stage of syphilis infection, the individual typically develops a rough, non-pruritic, red or brown skin rash and lesions of the mucosa. The patient may also experience fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. This secondary stage will also resolve without treatment; however, without treatment the disease will progress to the latent stage. This final stage is characterized by progression to a chronic, systemic course which eventually results in ataxia, paralysis, parasthesia, blindness, and dementia. A single IM injection of penicillin will easily cure syphilis in individuals who have had the infection for less than one year. Recurrent doses of antibiotics are necessary to clear up more advanced stages of the disease. Sexual partners should also be identified and treated in order to prevent further spread within the community.

Trichomoniasis results from infection with a single-celled protozoan parasite, trichomonas vaginalis. Trichomoniasis infections are the most commonly occurring curable STD in young sexually active women. As with many STDs, trichomoniasis infection may be present even in the absence of symptoms. When symptoms are present they include frothy, yellow-green, offensive vaginal discharge, painful intercourse and urination, and itching and irritation of the genital area. Pelvic examination may reveal small red ulcerations on the vaginal walls and/or cervix. Trichomoniasis is usually successfully treated by prescribing metronidazole. Sexual partners should also be identified and treated. Infected individuals should abstain from intercourse until medication is completed and symptoms resolve.

Cates, W., Jr. (1999). Estimates of the incidence and prevalence of sexually transmitted diseases in the United States. Sexual Transmission of Disease, 4, S2-7.

Feder, A. (2006). Management of STIs in women. Primary Health Care, 16, 31-32.

Division of STD Prevention (DSTDP), Centers for Disease Control and Prevention Fact Sheets. Retrieved online 7/31/06 from http://www.cdc.gov/std/trichomonas/STDFact-Trichomoniasis.htm