ATTITUDES TO V.D. OR STD
by Major M. P. Vora
August 13, 1991
The term V.D is apt, brief and precise for sexually or asexually transmitted or acquired venereal diseases. It has been changed to STD in order to soften the public attitudes towards these diseases, with little success. It has caused only confusion in the minds of the public.
The STD’s, as they are called today, are “The most formidable enemies of the human race, entrenched behind the strongest emotions and deepest prejudices; they are related to the sex life of a man, shrouded in reticence and secrecy, treated in silence, concealment and taboo. They are steeped in ignorance and saturated with prejudices.”
They provoke divergent reactions among the public either educated or ignorant. The study of various attitudes and reactions of the people to STDs, which pose a constant threat to the public health, is likely to provide an interesting insight into the public thinking. Before touching the subject proper, a few instances that have actually occurred will be welcome.
In 1927-28, when the population of Bombay city was small, the number of venereal diseases was only five and the incidence of V.D. was not large, Bombay city had three separate and autonomous V.D. clinics, started by the State i.e. in J.J.Hospital, St.George’s Hospital and Cama Hospital for women. They continued to function satisfactorily under great difficulties, and earned public probation, inviting a financial offer from the WHO in1950-52 for a V.D Training Centre in Bombay. However, in 1972-73 V.D. clinics came to a sudden end with a new policy of dermato-venereology that came into existence arbitrarily and without prior discussions or explanation, combining skin and V.D. departments together. This harmful change went without comments. It is difficult to understand why the old system, which existed for nearly 35 years and earned praise for conscientious work was suddenly changed. This has significantly lowered the standards of teaching and services in venereology in particular. It has devastating effects especially today, when the numbers of venereal diseases have increased to more than thirty five and the incidence of V.D. has shot up very high and sky-rocketed. What caused this sudden change in the State’s health policy regarding V.D. education and services is a great mystery. It shows a significant change in their thinking in 1927 and in 1973? It is certainly inconsistent and devoid of mature thinking. Besides, one learns now authentically, that the State has started full V.D. Complex at Nagpur lately. But who cares, what is politically palatable is done.
V.D.s are transmitted mainly through sexual intercourse either illicit, licit or occasionally asexually by accident. However V.D. asexually transmitted or acquired is uncommon. Yet it is quite common to come across some persons even among the medical men and nurses as in the public, who fancy that V.D. is acquired by entering a V.D. clinic, shaking hands with a venereologist, using public urinals or latrines, cycling for a long time, heavy weight lifting or taking a peg of whiskey. Most people regard a patient of V.D. as promiscuous and as a less worthy soul, who deserves no sympathy or consideration what-so-ever. This harsh, careless attitude and uncouth, graceless behavior towards these patients are found at times even among the medical profession. Many medical professionals believe that the subject of V.D. has been too long traditionally with the inferiors and less gifted doctors called the V.D. specialists. Outside venereology the medical profession has among its highest ranks, a few who regard venereology as unworthy of special study or attention and many of them remain ignorant of its wide horizons, growing importance and new developments. It is no wonder that there are a few recruits who are interested in this subject and who would like to make venereology as their life work.
People’s attitude to STD is prejudiced partly by their ignorance and partly by their assumption of illicit sex relation or violation of moral code of conduct. This is the genesis of unpleasant connotation associated with the term V.D. The people have compassion and deep concern for the patient with typhoid or T.B. but severe condemnation and dislike for the V.D. patient. Authorities and health departments in the country show scant attention to V.D. and its problems; they are disinclined to appreciate good work done or services rendered by devoted doctors or social workers, leave aside a word of praise or any incentive.
The attitude of the V.D. patient is the same as that of the public in general. For many, there is sense of shame, repentance, psychological impact, changed self image and bewilderment. Threats of reprisal are less common. The diagnosis of V.D is accepted calmly and with forgiveness by some, while by others with great upset and excitement. There is an urgent need for an early and precise diagnosis, thorough treatment, tests of ‘cure’ and curbing the spread of infection to others. Doctors often ask the patients about their wife, husband or friend; but patients are unwilling to tell about them. When pressed they say their partners are all right and have no complaints. STD patients must be told that the persons without symptoms are the frequent carriers of these diseases and their full cooperation is needed to bring their sex partners for examination and treatment if necessary. The fact needs to be well emphasized. Some patients pretend to be Don Juans; others know that they can be cured quickly by modern drugs and are bold enough to expose themselves repeatedly to V.D. A few persons shun special clinics and seek advice from their friends or quacks, and go on infecting others with least concern and gay abandonment, till overcome by serious complication or disability. Married persons are under constant fear of domestic trouble. They are deeply concerned about their spouses (wives or husbands) reactions, should they find out or come to know. Feelings of guilt and remorse are constant on their minds.
An average medical man’s knowledge about V.D. is usually bizarre. Usually 8 to 10 hours, spread over three weeks are allotted for the study and practical experience, often under a medical officer with limited knowledge and experience of V.D. Often students sign the roll call and run away without reproach. Venereology is considered of no importance. This is the state of the world’s third most prevalent infectious group of diseases. De-recognition of the subject, failure to give due importance to its teaching and practical experience and total neglect by universities, medical council, health authorities and the states and medical educationists are responsible for the present state. It is known fact that a lack of proper education, training and practical experience reduce very sharply diagnostic and therapeutic yields and at the same time, increase the risk of the spread of venereal infections in the community. Venereology has been reduced to little importance, indeed.
V.D.s are endemic in all countries of the world. Sexual transmission has been implicated as an important factor. An infected sex partner always exists often without symptoms. Investigation and treatment of the sexual partner is very important but often neglected in the country. A failure to comply with even in one case implies a serious failure from the point of the community and the patient too. It is mandatory for a doctor, who treats a venereal patient to fulfill this obligation. The role of counseling to reduce the spread of these diseases is increasingly realized in the advanced countries but not in our country, unfortunately. The studied indifference towards the subject is shocking.
During the last years, there has been in the country, a sustained and substantial increase in the number of diseases and continuous rise in their incidence and prevalence. Both the older group and the newer group of more than thirty diseases share many common features such as contagiousness, sexual contact, different etiology, specific diagnostic procedures, treatment, tracing the sex contacts, their examinations and treatment, epidemiology, tests of cure micro-bacterial and serologic after the therapy, documentation, maintaining individual records, statistics, auditing etc. But most of these details are very often neglected. This is rarely done in the dermato-venereology. This is one of the reasons why venereology deserves to be recognized as a separate entity in the medical colleges and teaching hospitals. A person without symptoms always exists as a carrier of infection; awareness of this fact should help to improve and enhance medical services such as an early detection of V.D. and prompt treatment, contact tracing etc. Newer knowledge of V.D. has revolutionized the care of V.D patients. However, this has no place in the country. Today, good health maintenance practice stresses public health education and employment of various screening tests. These prophylactic measures in persons aged between 15 to 35 or 40, identified at high risk for contracting V.D., deserve special mention. Tests for syphilis, urethritis, AIDS, PID (Pelvic Inflammatory Diseases), mycoplasma, virus etc. should be carried out in adults, adolescents, youths, persons seeking jobs, or seeking admission into hospitals as a part of physical examination, candidates who wish to marry, patients in the ante-natal or gynic care, etc. Tests ought to become aggressively routine in all hospitals in the country. They are not very costly or effectively reduce the chances of spread of V.D. to others. The results of the tests done must be reliable and in the hands of well-experienced persons. This is a valuable procedure for preventive medicine and the main stay for the V.D control. For this well-planned and well-equipped venereal disease laboratories and trained and experienced technical personnel are a must for every venereal department for precise diagnosis, proper treatment and declaration of ‘cure’ after the therapy. Unfortunately, this does not find a place everywhere in the present set-up even to this day. Without such essential facilities, how can there be a hallmark of perfection. Proper and up-to-date records of tests done and their results have to be kept regularly. National standards must be strictly adhered to. Persons doing sophisticated tests must be well experienced and devoted workers. Strict privacy and confidentiality have to be maintained. Laboratories doing these tests ought to be registered and occasionally have to submit to a group of verification and reliability exercises to prove their results are reliable and trust-worthy. But the present gloomy outlook may be symbolic of our authority’s attitude towards the subject.
In the country, AIDS (Acquired Immune Deficiency Syndrome) is currently receiving a major attention from the press and financial help from health authorities; while there is total neglect and disregard for other V.D.s which is in large numbers (35to40) and comprises risk factors. To concentrate on AIDS alone and to totally neglect many other V.D.s is hazardous and imprudent. This is a serious error and reveals gross ignorance of the health authorities and the press. It would be fair and reasonable, if all the V.D.s is treated with equal attention; concern and care, for all are capable of spreading and causing havoc.
AIDS is an integral part of V.D.s and merges with them. It is the domain of the venereologists. Venereologists ought to have been actually in the fore-front in the active campaign against it, its education, treatment and control. But the medical authorities have strangely dissociated them from it and denied them active participation. They have no courtesy to invite representatives of the I.A.S.S.T.D. (Indian Association of Sexually Transmitted Diseases). They depend on the new breed of internists and virologists and epidemiologists. In the western countries, where AIDS is common, venereologists are actively involved and entirely manage them.
AIDS is a world wide serious medical problem. It is caused by HIV (Human Immuno Deficiency Virus 1 and 2) infection. It selectively affects the humans and their T-lymphocytes and causes a steep decline in the number of cells and loss of their function. As a result one’s immune system is affected worst and the body becomes an easy prey to many opportunistic infections and diseases. The incubation period varies widely. It is two years for a child and 3 to 5 years for an adult, following affected blood transfusion and 8 to 10 years for an adult infected by sexual contact. Because of the profound loss of immune power, the victim is unable to repeal disease carrying germs. Virus is caught during sexual contacts- heterosexual, homosexual, oral or anal, from mother to her infant, contaminated blood and blood products, body fluids, shaving razors, tooth-brushes, semen, sperms, body organs, needles, syringes, surgical instruments etc are likely to carry virus to another. Following the infection, the disease may take a wild form or a full-blown with serious complications. There is a profound depletion of cell-mediated immunity because of loss of lymphocytes. It may cause diverse signs and symptoms, such as fever, arthritis, body ache, cramps, diarrhea, frequent attacks of infections- bacterial, viral or fungal, gastroenteritis, neuralgic, psychiatric or brain infections, lung affection, malignant tumors, sarcoma, etc. There is no end to repeated infections. This deadly sexual disease is spreading fast all over the world. So far there is no specific drug for it or an effective vaccine against it. In order to protect against this infection, every health worker, doctor, laboratory technicians, trainees are strongly advised to look at all patients as potentially infected with AIDS and take special care. Vice versa a doctor with HIV can pass on the disease to his patient while doing professional work. To protect against this infection;
Venereal diseases have been endemic and there is no sign of their decline. A significant new factor or aspect of V.D. epidemiology is the growing incidence of homosexuality and modified sexual practices involving many partners. Also there is organized sexual abuse of children by unscrupulous elderly members of the society, often concealed by ignorance and indifference, causing ravage of the children. There is no reliable estimate of the prevalence and incidence of V.D. in the country, though they are most common and frequent. Not only have the number of diseases multiplied seven times but also their frequencies have gone up markedly. There is an enormous discrepancy between the reported and estimated cases of V.D. The cases treated by private doctors and hospitals are rarely reported; there is no way to find them. There are often no proper facilities for precise diagnosis, records of the patients and statistics; all this leads to under-estimate and under-score the actual figure of V.D. In fact, the number of venereal cases far surpass those treated in a few government hospitals and those reported by authorities. It would be no exaggeration to say that the overall incidence of V.D. in India is about ten percent of the population and probably exceeds 8 to 9 crores annually. Persons between 15 to 35 years of age comprise nearly 80 percent. Isn’t it a significant problem and a major cause of morbidity, mortality and a huge economic loss to the nation? Crores of rupees are spent yearly on the so-called education of the masses but very little is done to educate the public about the V.D.s or to make available good facilities for diagnosis and treatment of venereal diseases. Here is an example of gross neglecting of V.D. in our country. “The V.D. subcommittee of the Planning Commission of India had recommended, more than forty years ago, one V.D. clinic in every district hospital.” Even to this day, this modest recommendation could not be fulfilled by the health authorities in the country. Mass education programs involving radios, TVs, films, well-planned lectures, pamphlets, slides, newspapers both private, social and government agencies are of prime importance. These must be ongoing and never ending. But what is most disturbing is the total apathy, indifference and unresponsiveness on the part of authorities and the public alike.
The present chaotic state of medical education (venereal) and training services to the patients and distorted pictures of V.D. or skin V.D. departments are primarily related to gross apathy and total indifference of the authorities, medical educationists, I.M.C., their wavering or inconsistent policies, refusal to accept guidance or suggestions, wrong attitude towards V.D. departments and scanty knowledge about the subject. Hospital authorities think that if they can allot a small room 12 by 12 feet for the specialist to examine and treat V.D. patients, their responsibilities ends. They are not amenable to reasoning; they have no sympathy but strong contempt for the patient and little respect for the specialist. The result is unplanned, ill-equipped and sham clinics incapable of good work. Suggestions made by experts, both nationals and foreigners, from time to time, to improve and up-date working conditions and services are totally ignored. Up-to-date management of V.D. patients, on the internationally acceptable standards can promote significant advances in education, services, and modern trends in V.D. therapy. Unanimity of opinions does exist on the recognition of venereology as an important subject and keeping it separate and that it is in urgent need of recognition but there is no sign of its genuine acceptance uniformly in all states of the country. Once this basic principle is recognized and accepted, special clinics with proper standards are established, this will allow the preventive approaches to succeed with the abilities of trained and experienced staff and paramedical personnel, fully devoted to the cause. It will permit utilization of recent advances in various fields in venereology. In the beginning or the early stages, a strict constant watch and supervision of the clinics and their various works are very necessary to inculcate proper procedures, practices and right trends. Effectiveness of the efforts depends directly on the speed with which patients are seen and to with primary care in strict privacy which has to be respected. Besides, there must be a mobile van specially designed and equipped with diagnostic and therapeutic services to regularly cover the surrounding areas to serve the public.
V.D. is no more a penalty for one, who knows about it. It is not a deterrent against a risk of exposure to infection. It remains a grave hidden and growing menace to the ignorant and indifferent. A good venereologist neither judges nor accuses his patients. However, a word of advice to the young and ignorant and an occasional rebuke for the one who infects his wife or a spouse, in spite of a previous warning, may be scolded bluntly. The specialists’ chief concern is for the civilized and responsible approach to the subject of sex, its knowledge and its implications i.e. unwanted pregnancy, venereal infection and its spread to others. A close cooperation among various workers in the good clinic is always available and results in prompt, efficient work and quick service. A smooth team work invariably results. The patients trust and cooperation is always implicit. All these attributes are invariably found in an ideal venereal clinic, which should provide a convenient “window” for the public guidance and knowledge. In absolute contrast , most of the clinics in the country- they are few and far between and often in the name only- are entirely devoid of the essential features and lack proper and experienced team work and services.
The management of venereal patients can no longer be left to the novice or amateur; it must be entrusted to the trained and experienced professionals. But the total apathy about the subject in the country is very tragic and distressing. Authorities in the country have cast away recklessly great opportunities to brighten their images and uphold healthy conventions. There is an urgent need to build a coordinated national standards and procedures in respect to venereal clinics and staff, proper management, record-keeping, statistics, auditing and to encourage an ambulatory mode of service for the diagnosis and treatment for the rural population. This is a dire necessity today. Will the Central and the State authorities think seriously and act promptly on this urgent subject? There is no effective way to reverse the present course of falling standards in the management of STD or V.D.
It is the hormones which define male and female and set them apart and cause many physical, psychological and sexual problems. To overcome these sex made differences provide both the challenge and frustration to the relationship between men and women. Today’s youth grown under modern or western culture and given to new film styles, is free from family influences and traditions; he has an altered moral code, is full of instinctive curiosity and belongs to the group, tending to be promiscuous. His famous slogan is, “Teenagers of the world, unite for sexual bonanza; you have nothing to lose except your orgasm, but an orgasm a day does not keep the doctor away”. He is inclined to regard V.D. as an accident of sexual activity. Some youths deal with it quickly and effectively and forget about it; while others are content with mere relief of their symptoms. They have no compunction in infecting their friends and associates. Permissiveness is charged with strong emotion and it is difficult to decide what one’s attitude should be. Excessive virtue as a goal and very strict outlook are certainly undesirable and difficult to achieve; so also extremes of debauchery or moral degradation are difficult to tolerate and bear. One would not like parental tyranny and welcome reduction in sexual hypocrisy. However, moderation born out of tolerance seems to be have been carried to excess, and in its wake is the steady and steep rise in the incidence of V.D. ever know as a peace- time phenomenon. As the result of the pill or loop, which permits the female freedom from conception, there has been a steep rise in premarital, extramarital and promiscuous sexual relations, following sexual liberation of the female. This is quite obvious today, from the growing female contribution to the incidence of V.D. in the country and in the world. However, many young females are unaware of the fact that the pill or loop does not protect them from or against V.D. What would be one’s reaction, when a wife’s fun-sex, by chance, results in reproductive sex or extramarital conception by miscalculation and independent of her husband, or a young girl’s fun-sex ends in V.D. and/or clandestine pregnancy? The bulk of female partners are not necessarily promiscuous but are usually secondary contacts. Whatever may be one’s conscience regarding sexual indulgence, the consequences are usually the same. Pregnancy, V.D. and infertility or sterility due to the pelvic inflammatory diseases are natural sequels of promiscuity, which is the sine qua non of the venereal disease but it affects a few. There will be decrease in promiscuity only when the permissive society will decide on the clear dividing lines between what is normally permissible and acceptable sex and what is an excess and unacceptable sex, what might be the best and reasonable course of their acceptance and compliance by all. It takes three, not two, to provide one case of V.D. and only one them need to be a habitually promiscuous person. A married man may have only one extra-marital relation in his life, but if the girl is promiscuous, the man pays heavily for his indulgence by contracting the infection (V.D) and passing it to his wife. Though sexual promiscuity is the basis of the V.D. problem, the repercussions extend to involve anyone, who roams usually beyond the bounds of a regular and stable partnership. The aspect of a permissive society as it concerns the venereologists is that more women offer themselves for sexual relations today, than in the past. May be it is the more tolerant society but for the majority, it is a licentious and vicious society. There are many standards for sexual behaviors as there are people behaving sexually. Some observe monogamy, some polygamy while others follow homosexuality, oral sex like fellatio and cunnilingus. However, most agree in forbidding all forms of antisocial sexuality as rape, child misuse or exhibitionism. Few will willingly approve of extra-marital liaisons inside a marriage. Yet many are quick to disapprove and condemn sexual intercourse between two unmarried people, deeply in true love and in holy or divine relationship, occurring under incessant and unconquerable passion for sexual union. STDs have two sides worthy of consideration. Indirectly, through love, sexual intercourse being for the mutual gratification of both the man’s and the women’s basic procreative instinct, is capable of his or her noblest thoughts, aspirations, achievements and conductive to their mutual happiness. Herein the sex relation is of the most important form of human activity known to the man for elevation of mood, maintaining a sense of well being and contributing good and meaningful life for both the man and women in general, and the society in particular. Still, when profligate sex leads to unwanted pregnancy or in V.D., it gives rise to moral degradation, remorse, viciousness, mutual disrespect, loss of self esteem and domestic unhappiness. Thus on one side of the coin are Victorian prudery, fear and contempt and on the other side are hilarity, laughter and ribaldry.
The educational program for the youth should be aimed at civilization, citizenship and adulthood rather than adultery. An appeal should be made to one’s idealism of the youth, personal pride, self-esteem and responsibility. This approach is far more effective then scolding and rebukes. Youth should be told plainly that love should not be confused with lust and avid for sensual desire for flesh. It is no use to harp on sin and stupidity. They must be made aware of dire consequences of V.D. and mental distress from reckless and licentious sex. Some youngsters who are bright and mentally and emotionally ahead of others can be trusted to look after themselves. But, let us pity the ignorant youngster, who finds herself with unwanted pregnancy and/or venereal disease and condemn the heartless man, who exploited her in full awareness of what he was doing. With more liberal approach to sexual matters, it would be possible to put an end to absurd taboos, baseless fears, sexual anxieties an neurosis, that often haunt their minds frequently. But this concept and tolerance of their human problems must not put us to difficulties; it should end in helpful aspect of personal intimacy. In fact, we are all involved closely with their intimate and integral problems. A saner balance between the past Puritanism and our present sexual over concern should certainly help to overcome differences. One should desist from pointing out an accusing finger at the younger generation. One should rather point to the controller of mass media of communications such as T.V., Radio, films, press and social bodies, etc in whose power lays the future sanctity of mankind and human happiness. But all of them need to be shaken and awakened from their deep slumber. There is an urgent need of carefully planned educational programs, ever on-going and never ending, to educate the young masses about the venereal diseases. To recognize these diseases in the earliest stages presents a real challenge; for, most of the persons with infection are without symptoms and the carriers of infections. These diseases are easy to control, if they are precisely diagnosed, treated early and fully followed by tests of cure bacteriologic and serologic- and their sex partners are located and induced to go for an examination and tests and treated to curb the spread of their diseases to others. A talk of V.D. control is absurd, when proper facilities for their diagnosis and treatment are absent all over the country. It is a fact that venereology and venereologists have often received a raw deal from the health planners and administrators. Budget allocations are either meager or often used for the skin instead of V.D. in a joint department of the skin and V.D. It is very difficult to gauge the extent of damage that follows a joint skin and V.D department. The education and training facilities for the under-graduates and post-graduates, paramedical staff are totally neglected. There is no uniformity of patterns of education and services. There is an urgent need to train paramedical workers like nurses, social workers, laboratory technicians, record keepers, statisticians, etc. It is high time to bring about proper changes. The country is already paying a high price for the total neglect of this branch of medicine. There is an unexplained total lack of interest and continued negligence about the subject, its education, and training, medical services. Venereology has no place in the medical colleges and teaching hospitals, though it had prima facie a very strong case for independent existence.
Most major advances in the medical knowledge came about as the result of specialization. This trend is, therefore, essential if medical knowledge is to advance and the sick are to get modern and expert line of treatment and recover from illness quickly. The recent extension of specialization is excellent, necessary for natural development of modern medicine. To obstruct the free flow of specialization in the growing medicine would be ruinous.
It will be apt and well suited to plead strongly for a comprehensive survey of medical education, training and services, concerning V.D. in the country. The result will be shocking. The urgent need is to educate the public about these diseases to protect their own health and that of others from the diseases. We urgently need to harmonize our V.D. standards with those of the global quality or international standards. We need to develop proper diagnostic procedures to achieve excellence and reliability. There is broad consensus that venereology must be treated as a separate subject. The need to change our present attitude towards these diseases and the patients with V.D. is urgent. We have to fight social stigma attached to these diseases and patients. To ignore this problem is to slide towards medical bankruptcy. For years we have blundered badly in the total neglect of its teaching and proper management. Our short-sighted bureaucracy must be restrained from playing petty divisible politics for its own selfish ends or to appease their political masters. In the realm of decision-making, the same leaders have not only brought our medical (venereal) education and services to the brink of bankruptcy by constantly ignoring sober and earnest advices of the experts in venereology. It would be grievous mistake to allow impediments in the proper and natural growth and development of venereology. They simply hinder the proper procedures and natural growth. It is quite possible that our authorities are not immune to the prevalent attitudes to V.D. and unable to think or deal with the problems associated with venereal diseases. A total absence of interest and inherent dislike for the topics connected with V.D. continue and may have deprived them from right thinking and proper acting. It is sincerely hoped that proper and long over-due changes in respect of venereology will win and succeed for; venereology has prima facie a very strong case of independent existence.