On Being Clean
Originally published at Welcome To The Dollhouse. You can comment here or there.
I originally wrote a version of this post back in 2006, but as this was ages ago in blog time, I’ve revisited the topic for 2009.
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.3unclean or dirty. 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
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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