‘Are you monogamous?’
She looked down as I talked to her. I am not sure if it was fear, shame or a mixture of both. I was glad that the female nurse was there with me to witness the conversation and hold this 20 year old girl’s hand.
‘I don’t know what that means, she answered.’
‘Do you have more than one sexual partner?’
‘Not in the last 4 months.’
I moved on; ‘I wish I could tell you something different, but these warts in your private parts are not only difficult to treat, but you most likely never be able to have sexual intercourse without the chance of spreading them to your partner.’
I hate this kind of discourse, because I feel as though I am inflicting deeper wounds and I only have 15 minutes to do so and then try to stitch it back together in a nice package of correct diagnosis and codes. Medicine and compassion don’t mix in today’s fast paced, need to fix it now and save money at the same time culture.
What makes it worse is this is the difficult ‘good news- bad news’ kind of conversation. That is the good news being you won’t infect anybody if you don’t have sex and the bad news is you should not have sex. It is not what any one wants to hear, especially upon entering the second decade in life.
If I tell the truth, I am going to accused or at least perceived as being cold, callused, uncaring and possibly even unprofessional by many and a narrow minded conservative bigot by others. I sit and ponder the dilemma at my desk for a few minutes, knowing that most likely whatever I say, I must neither betray, nor display my moral convictions. I can only give my well thought out scientific professional opinion.
As I consider the nationwide statistics I have no other choice than to confront the person in front of me as if she bore some dreaded contagion shown on horror movies. The CDC is well aware of the contagion that confronts the nation and world, and documents it in several of its publications.
Just one illness alone is cause for alarm. In 2011, a total of 1,412,791 cases of Chlamydia trachomatis infection were reported to the Centers for Disease Control and Prevention (CDC). This is the largest number of cases ever reported to CDC for any condition. This case count corresponds to arate of 457.6 cases per 100,000 population, an increase of 8.0% compared with the rate in 2010. Rates of reported chlamydial infections among women have been increasing annually since the late 1980s, when public programs for screening and treatment of women were first established to avert pelvic inflammatory disease (PID) and related complications. (http://www.cdc.gov/std/stats11/Surv2011.pdf)
This same report goes on to document the continued rise in every disease category including the prevalence of syphilis and gonorrhea in select groups: These populations are most vulnerable to STDs and their consequences. They include women and infants, adolescents and young adults, racial and ethnic minorities, MSM (men who have sex with men), and persons entering corrections facilities.
My personal bias is that poverty and poor or absent parenting plays a significant role in much of this profile. However, I would be remiss to add that my clinic is not in an impoverished area and most of the youngest patients are accompanied by their parents.
In 2011 the first and second highest rates of gonorrhea were amongst women 20-24 and 15-19 years of age. The steady increase in these illnesses is mirrored in men in the same age brackets.
So I still tread lightly when giving my professional opinion as I know it will not be received well.
I return to the room where she remains seated, with her head hung low. I remain silent, hoping she will start the conversation. She complies.
‘So what can I do’ she asked?
I always continue such conversations with a verbal sigh; ‘Well, to tell you the truth, the most important thing to do at this point is to test you for other potential illnesses.’ I dare not use the word ‘diseases’ knowing full well at least from a professional point of view these options are potentially deadly or crippling in nature.
‘We can draw some blood tests now and schedule you for tests at 6 weeks, twelve weeks and twenty four weeks to confirm the results. During that interval, you must abstain from sexual intercourse. There is no safe sex. Do you understand?’
She nods in affirmation, while keeping her downward gaze.
I leave the room quickly and the nurse follows closely behind, as we discuss how many tubes of blood and what color and label need to go with them. This varies of course depending on the insurance provider. I don’t return to the room. There are too many people waiting to be seen is my excuse, but truthfully, I just don’t know how to deal with the unfolding drama in her mind. I think I have actually poured salt in a wound that won’t heal.