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Sexually Transmitted Diseases

Dr. Ramsha Zafar
Physician/Internal Medicine
Freelance Writer

Sexually Transmitted Diseases
جنسی طور پر مُنتقل ہونے والی بیماریاں
यौन संचारित रोगों
“YOUR BODY YOUR RESPONSIBILITY
TAKE CARE OF IT BY PREVENTING STDs”

Sexually transmitted diseases (STDs), also known as sexually transmitted infections (STIs), are infections primarily spread through sexual contact. These diseases pose significant public health challenges worldwide due to their prevalence, impact on health, and potential for serious complications. Previously referred to as sexually transmitted diseases, sexually transmitted infections (STIs) are caused by the transfer of an organism between sexual partners through various routes of sexual contact, such as oral, anal, or vaginal. Everyone is susceptible to STIs, but they can be avoided with appropriate information and barrier management. Eight pathogens are linked to the most prevalent sexually transmitted infections (STIs) including both treatable (herpes viruses, human papillomavirus, human immunodeficiency virus) and curable (gonorrhea, chlamydia, syphilis, trichomonas). The associated symptoms can be classified into two groups: ulcerative lesions and discharge/dysuria. Patient behavior, underlying comorbidities, and illness prevalence all affect the chance of developing these disorders. To stop the transmission of disease, reduce morbidity and death, early detection and screening for STIs are essential. These infections are more common in medically deprived groups and are often underrecognized.

Syphilis Vectors & Illustrations for Free Download | Freepik

If left untreated, STIs can cause serious health problems, including cervical cancer, liver disease, pelvic inflammatory disease (PID), infertility, and pregnancy problems. Having some STIs (such as chancroid, herpes, syphilis, and trichomoniasis) can increase your risk of acquiring HIV if you are HIV-negative and are exposed to HIV. People living with HIV may also be at greater risk of getting or passing on other STIs. When people living with HIV get STIs, they can experience more serious problems from them or find it more difficult to get rid of these infections. Regardless of race or age, less than half of those who should be tested for STIs are actually tested. This is especially important for women, since women suffer more frequent and more serious complications from STIs than men.

Signs of Sexually Transmitted Infection (STI) in Females

Syphilis Vectors & Illustrations for Free Download | Freepik

Many STIs have no symptoms but can still be passed from person to person. A lot of people who have an STI do not even know it. They may be healthy, and still have an STI. It is not possible to tell a person has an STI just by looking at them. The only way to know for sure is to get tested – to have regular sexual health screenings by your health care provider.

While many people with STIs show no signs or symptoms of their infection, when there are signs of STIs, they are most likely in the genital area. The genital area in some people, including cisgender women, includes the vulva (the area around the vagina including the lips), vagina (the opening where menstrual blood comes out), buttocks, urethra (the opening above the vagina where urine comes out) and anus (the opening where a bowel movement – “poop” – comes out). The genital area in others, including cisgender men, includes the penis, scrotum (“balls”), urethra (the tube through which urine passes through the penis), and anus.

Fortunately, you can reduce your chances of getting many STIs by practicing safer sex. Most STIs, though not all, can be successfully cured through treatment. For other STIs, there are effective medications that can help you manage your condition.

Sexually Transmitted Disease Images - Free Download on Freepik

Sexually transmitted diseases (STDs) are a significant public health concern worldwide, and Pakistan is no exception.

Reproductive tract infections do not always correspond to sexually transmitted infections (STIs), nor do all STIs cause reproductive tract infections. Reproductive tract infection refers to the infection site, whereas the “ST” in “STI” indicates the mode of infection transmission. Four treatable sexually transmitted infections (STIs)—gonorrhea, chlamydia, syphilis, and trichomoniasis—saw 340 million new cases in 1999. These infections are a significant worldwide health issue that cause stigma, morbidity, and mortality. Since the start of the HIV/AIDS epidemic, STI control has been prioritized due to its role in enabling the sexual transmission of HIV.

Symptoms

STDs can have a range of symptoms, including no symptoms. That’s why sexually transmitted infections may go unnoticed until a person has complications or a partner is diagnosed.

STI symptoms might include:

  • Sores or bumps on the genitals or in the oral or rectal area.
  • Painful or burning urination.
  • Discharge from the penis.
  • Unusual or odorous vaginal discharge.
  • Unusual vaginal bleeding.
  • Pain during sex.
  • Sore, swollen lymph nodes, particularly in the groin but sometimes more widespread.
  • Lower abdominal pain.
  • Fever.
  • Rash over the trunk, hands or feet.

Sexually transmitted infection symptoms may appear a few days after exposure. But it may take years before you have any noticeable problems, depending on what’s causing the STI.

HIV cases have been rising in Pakistan, especially among high-risk populations, in recent years. As of June 2023, Pakistan’s National AIDS Control Program (NACP) reported 60,439 HIV cases, with 38,234 people receiving treatment at the country’s 74 ART centers. In 2022, Punjab province had the highest number of new cases with 6,106, followed by Sindh with 2,096. 

Pakistan has been a hub of several HIV outbreaks over the last 2 decades. There has been a recent rise in HIV infections especially in high-risk populations. Reasons include poor infection control, questionable ethical practices, and no awareness.

Moderately high drug use and lack of acceptance that non-marital sex is common in the society have allowed the HIV epidemic to take hold in Pakistan, mainly among injecting drug users (IDU), male, female and transvestite sex workers  as well as the repatriated migrant workers.

Premium Photo | Sexually Transmitted Diseases Community Health Connection background

Many STIs have no symptoms but can still be passed from person to person

Pakistan is the second most populous Muslim-majority country, with an estimated population of 169 639 500 in 2010. Religious and social ethics are highly admired and deeply ingrained in the Pakistani society. Despite the high regard for religious and social ethics in Pakistani society, sexually transmitted diseases (STDs) remain common due to factors like lack of sexual health education, stigma surrounding sexual practices, and limited access to healthcare services. These challenges contribute to risky behaviors and hinder efforts to control the spread of STDs.

The extent of the issue

Globally, STIs have a significant effect on sexual and reproductive health. Every day, about a million STIs that are treatable are contracted. WHO projected that 374 million new cases of one of the four STIs—gonorrhea (82 million), syphilis (7.1 million), trichomoniasis (156 million), and chlamydia (129 million)—will be reported in 2020. In 2016, it was projected that over 490 million people had genital herpes, and 300 million women were infected with HPV, which is the main cause of anal and cervical cancer in men who have intercourse with other men. Furthermore, according to current estimates from the WHO, 254 million people had hepatitis B in 2022.

Prostitution in Pakistan

Women in the underdeveloped countries are deprived of basic rights and are exploited through physical violence, forced marriages, life threat, fake love affairs, runaway and sexual abuses. The conservative mindsets of the male-dominant society do not accept the women with follies. Whenever a woman put a step out of her home even for a work, the evil eyes of the men always gaze at her. There is no rule set to study the women empowerment which would enable women to arise question on the existing empowerment.

Page 2 | Prostitution Vectors & Illustrations for Free Download | Freepik

A female’s beauty and physique are the symbols of attraction for men. Men always respect their daughters, sisters, mothers and wives, but the other women are just a flesh for men to fulfill their sexual desires. Mostly, males used their wives for their sexual companionship, but some of them hire prostitutes for their violent sexual appeals. The sexual violence, rapes and even child abuses are the consequences of aggressive sexual stimulations. Sexually violent males are said to be different than other men, and anti-social tendencies also tend to have an exaggerated sense of masculinity. Sexual violence is associated with a preference for impersonal sexual relationship as opposed to emotional bonding and with the inclination to assert a personal interest. Prostitution is the result of sexual violence, and the difference in it is that it is paid and having the consent of the other party. Prostitution is a social evil which is arising in the society due to its high demands. Sexual violent demands and needs could be fulfilled through prostitutes. Prostitution is violence against women; many government policies have been made against the exploitation of women. Prostitution is a social violence, and it is the bottom of the society and there is no bottom beneath it; it is the abuse and oldest usage of women where the women have no value even lying in the bottom and all the men have more value than prostitutes. Prostitution is the business or routine with regard to participating in sexual activity in return for payment.

Illustrations by Areeshah Qureshi

The hidden realities behind prostitution could be poverty. In underdeveloped countries like Pakistan, the economic needs of a poor person cannot be met through low-wage jobs such as housemaid. So women mostly lying below the poverty level indulge in prostitution. Poverty is the base of all negative activities including prostitution especially in street prostitutes.

Prostitution, both legal and illegal, exists in Pakistan despite being officially banned and culturally stigmatized. Sex workers often operate in furtive environments, which makes them more vulnerable to various risks, including STDs. The following factors contribute to this vulnerability:

1. Stigma and Discrimination: Sex workers in Pakistan face severe social stigma and discrimination, which hinders their ability to seek health care and legal protection. This marginalization often forces them to operate in unsafe conditions, increasing their risk of STDs.

2. Economic Vulnerability: Many sex workers turn to this profession due to economic hardship. Financial instability often limits their ability to negotiate safe sex practices with clients, further elevating their risk of contracting and spreading STDs.

3. Lack of Education and Awareness: Limited access to education, especially sexual health education, leaves many sex workers uninformed about the risks of STDs and the importance of using protection such as condoms.

The Link Between Prostitution and STDs

High-Risk Behavior: Unprotected sex, multiple partners, and frequent sexual activity are common in the sex work industry. These behaviors significantly increase the likelihood of contracting and spreading STDs.

Lack of Access to Healthcare: Many sex workers do not have access to regular health check-ups, testing, and treatment for STDs. Fear of legal repercussions and social stigma often prevents them from seeking medical help.

Client Resistance to Protection: Clients may refuse to use condoms, and sex workers, fearing violence or loss of income, might be compelled to comply. This dynamic exacerbates the spread of STDs.

Prostitution and its association with sexually transmitted diseases (STDs) is a significant public health issue in Pakistan. Understanding this relationship requires a nuanced perspective that considers various social, economic, and health-related factors.

Homosexuality in Pakistan

Homosexuality in Pakistan, despite being criminalized and heavily stigmatized, contributes to the prevalence of sexually transmitted diseases (STDs) due to a complex interplay of socio-cultural, legal, and healthcare-related factors. Men who have sex with men (MSM) and other LGBTQ+ individuals often engage in high-risk behaviors due to the clandestine nature of their relationships, driven by fear of social ostracism and legal repercussions. This hidden status limits their access to accurate sexual health information, HIV/STD testing, and treatment services. The stigma and discrimination faced by the LGBTQ+ community in healthcare settings further exacerbate the issue, deterring individuals from seeking medical help. Unsafe sexual practices, such as unprotected sex, are more common among MSM due to a lack of education about prevention methods and limited access to condoms and lubricants. Moreover, the social isolation and marginalization of LGBTQ+ individuals often lead to mental health issues, which can result in substance abuse and further risky behaviors. The intersection of these factors creates an environment where STDs can spread more easily within the LGBTQ+ community and beyond, as infections can be transmitted to heterosexual partners and through bisexual behavior. Addressing this public health challenge requires decriminalizing homosexuality, reducing stigma, and ensuring accessible, confidential, and non-discriminatory healthcare services for all, regardless of sexual orientation or gender identity.

There has been a 369 percent increase in the number of AIDS-related deaths since 2010 | Fahim Siddiqi/White Star

The Transgender Community in Pakistan

Transgender individuals, known locally as “hijras,” “khawaja siras,” or “eunuchs,” have a recognized presence in Pakistani society. Historically, they have been marginalized and face significant social, economic, and health disparities. The Pakistani Supreme Court granted them legal recognition in 2009, yet they still face widespread discrimination and lack access to basic rights and services. Transgender people are around 13 times more likely to be HIV-positive than other adults of reproductive age.

Factors Contributing to STD Vulnerability

1. Social Stigma and Discrimination

0- Social Exclusion: Transgender people often face rejection from their families and communities, leading to social and economic marginalization.

0- Discrimination in Healthcare: Many transgender individuals experience discrimination in healthcare settings, which discourages them from seeking medical care, including STD testing and treatment.

2. Economic Marginalization

0- Limited Employment Opportunities: Due to societal discrimination, transgender individuals have limited access to formal employment, often leading them to engage in sex work as a means of survival.

0- Poverty: Economic hardship makes it challenging for transgender people to access healthcare services and preventive measures like condoms.

3. High-Risk Behaviors

0- Sex Work: A significant number of transgender individuals engage in sex work, which increases their risk of contracting and spreading STDs.

0- Substance Use: Substance use is prevalent in some segments of the transgender community, which can impair judgment and increase risky sexual behaviors.

4. Lack of Education and Awareness

0- Insufficient Sexual Health Education: Many transgender individuals lack access to comprehensive sexual health education, leading to limited knowledge about STDs and safe sex practices.

Public Health Implications

The high prevalence of STDs among transgender individuals has broader public health implications:

1. Transmission to Other Populations: Transgender sex workers often have clients from the general population, potentially leading to the spread of STDs beyond the transgender community.

2. Increased Healthcare Burden: Higher rates of STDs contribute to the overall healthcare burden, straining limited healthcare resources in Pakistan.

3. Impact on HIV/AIDS Epidemic: Transgender individuals are at higher risk for HIV, which can exacerbate the HIV/AIDS epidemic in Pakistan if not addressed effectively.

Strategies for Mitigation

1. Targeted Health Interventions

0- STD Screening and Treatment: Implementing regular STD screening and accessible treatment services for transgender individuals is crucial.

0- Pre-Exposure Prophylaxis (PrEP): Providing PrEP to transgender individuals at high risk of HIV can help reduce the incidence of new infections.

2. Community Outreach and Education

0- Sexual Health Education: Developing and disseminating comprehensive sexual health education tailored to the transgender community can increase awareness and promote safe sex practices.

0- Peer Educator Programs: Training transgender individuals as peer educators can help bridge the gap between the community and healthcare services.

3. Policy and Legal Reforms

0- Anti-Discrimination Laws: Enforcing anti-discrimination laws to protect transgender individuals in healthcare settings and society at large.

0- Inclusive Healthcare Policies: Developing healthcare policies that specifically address the needs of transgender individuals, ensuring they have access to quality care.

4. Economic Empowerment

0- Employment Opportunities: Creating inclusive employment opportunities for transgender individuals can reduce their reliance on sex work and associated health risks.

0- Social Support Programs: Implementing social support programs to alleviate poverty and improve the overall well-being of transgender people.

In this picture taken on May 4, 2017, Saima Khan* comforts her child who was allegedly raped by a religious cleric in Kehror Pakka, Pakistan. ─ AP

Sodomy

Sodomy, traditionally defined as anal intercourse, is illegal and heavily stigmatized in Pakistan due to cultural, religious, and legal factors, contributing to significant public health challenges, particularly regarding sexually transmitted diseases (STDs). The criminalization of sodomy under Pakistan’s Penal Code imposes severe penalties, which marginalizes those engaging in such practices and deters them from seeking medical help due to fear of legal repercussions. The profound social stigma and discrimination surrounding sodomy and same-sex relationships push these activities underground, exacerbating the risk of STDs. High-risk behaviors associated with clandestine anal intercourse, such as unprotected sex and lack of knowledge about safe practices, increase the likelihood of contracting and spreading STDs, including HIV, as anal tissue is more prone to tears, facilitating infection transmission. Furthermore, the fear of exposure and subsequent punishment or ostracism prevents individuals from accessing regular testing, treatment, and education about safe sexual practices, contributing to the prevalence of STDs. The legal and social environment also imposes a significant mental health burden on those engaging in sodomy, leading to anxiety, depression, and substance abuse, which can further exacerbate risky sexual behaviors. Addressing these public health challenges requires decriminalizing sodomy, implementing legal reforms to protect individuals’ rights regardless of their sexual practices, and providing comprehensive sexual education that includes information about safe anal intercourse practices. Public health campaigns should aim to reduce stigma and promote the use of protection, such as condoms and lubricants, while ensuring healthcare services are accessible, confidential, and non-discriminatory. Training healthcare providers to offer respectful and non-judgmental care can encourage more individuals to seek regular testing and treatment. Community engagement is also crucial, as working with community leaders and organizations to promote acceptance and understanding of diverse sexual practices can help reduce stigma and create a more supportive environment for those at risk. By reducing stigma and providing the necessary support and resources, Pakistan can better manage and reduce the prevalence of STDs, ultimately promoting a healthier society.

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