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Hepatitis C is most often transmitted through contact with infected blood. Persons at especially high risk for hepatitis C infection are injection drug users, hemodialysis patients, and anyone who received multiple blood transfusions before 1990 (as did many people who have hemophilia). About 90 percent of posttransfusion hepatitis was caused by hepatitis C before the blood supply began to be screened for the disease in 1990. It is estimated that up to one out of every ten people who received a transfusion in the 1970s and 1980s was infected with hepatitis C. Since screening has been put in place, however, transfusion-related hepatitis has become rare.

Sharing needles in injection drug use poses a high risk of transmission. Tattooing with an unclean needle can also transmit hepatitis C. The chances of becoming infected from a needle-stick injury are estimated to be between 3.5 and 10 percent.

There is some debate about how easily hepatitis C can be transmitted sexually, although hepatitis B and HIV are almost certainly easier to transmit sexually than hepatitis C. Recent studies, however, indicate that sexual transmission of hepatitis C may be easier than was previously thought. Semen and vaginal secretions carry sufficient quantities of the virus for transmission. The risk increases with the duration of the relationship, and male-to-female transmission is more effective than female-to-male, as with most of the viral STDs. Transmission among same-sex couples has not been adequately studied. Those who have multiple sexual partners have a higher risk for hepatitis C infection than those with fewer partners. Combining these research findings with the fact that it is still unclear through which means many people infected with hepatitis C became infected, we must assume that sexual transmission is a possibility and that it may play a more important role than previously thought in the spread of the disease.

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There are several ways to test for chlamydia. Which method is appropriate for you depends on a number of factors, including which tests are handled routinely by the laboratory in your area, the cost of the tests, and which test your health care provider prefers. None of the tests is 100 percent accurate; accuracy can be affected by how well the specimen is stored on its way to the laboratory and the skill of the provider in collecting the specimen, among other factors.

The oldest way to test for chlamydia is to culture for it—that is, to rub a suspected infected area with a swab and try to grow the chlamydia in a special solution. Chlamydia is hard to grow in solution, however, so this test may have low accuracy. Other tests, called “non-culture tests,” were subsequently developed that looked either directly for proteins from the surface of the chlamydia (enzyme-linked immunosorbent assay [ELISA] and direct fluorescent-antibody assay [DFA]), or indirectly for the genetic material of the chlamydia (DNA probes). Yet these tests also missed many people who were infected.

Newer tests, the polymerase chain reaction and the ligase chain reaction (PCR and LCR, respectively), look directly for the genetic material of the bacterium and have over 90 percent accuracy, far better than that of the other tests. (This means that the test correctly identifies 90 out of 100 people who are infected.) The LCR can be performed from either swabs or urine in both men and women. These tests have now become the tests of choice in detecting genital chlamydia infection in men and women. For throat or anal chlamydia, however, culture is still the preferred test. The conjunctiva can be tested using the nonculture tests (ELISA, DFA, and DNA assays). Blood tests that look for antibodies, or the body’s immune response to previous infection with chlamydia, result in a positive test.

When someone is found to have chlamydia, decisions about what kind of medication is to be used, how long it is to be used, and what land of follow-up is necessary depend on the extent of the infection. In order to determine the extent of the infection, a physical examination is needed in addition to the screening test. For women, a pelvic examination must be done as part of the screening. Some women may test positive for chlamydia and have no evidence of infection on examination, whereas others have cervicitis or PID. In men who test positive for chlamydia, an examination may show no evidence of infection, or there may be signs of urethritis, epididymitis, or prostatitis.

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Education about STDs must be started early and include information about abstinence, as well as ways to protect oneself from becoming infected with an STD if one is sexually active. More and more young people are becoming sexually active at younger ages. Whether or not this is a good thing, it is a fact: teenagers account for about three million of the twelve million people infected with STDs in the United States each year, and two-thirds of those infected each year are younger than twenty-five.

Abstinence (not having sex) until you are older and better informed is the best solution.

Waiting to have sex allows a young person to develop as an individual and to focus on school and other interests. Young people who are already sexually active, however, need information on how to protect themselves from infection and pregnancy. Studies have shown that children who take sex education classes are actually less likely to engage in sexual activity, and if they do, they are more likely to use condoms. Education about STDs and safe sex is the first step in helping prevent infection.

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A cervix infection (mucopurulent cervicitis) can be caused by bacteria (such as gonorrhea and chlamydia), viruses (such as herpes), and protozoan infections (such as trichomonas). Unusual bleeding, including bleeding between periods and after intercourse, can occur from a cervix that is irritated for any reason. Other cervix conditions, such as cancer or a polyp (a small, noncancerous growth on the cervix), may sometimes also cause bleeding. A Pap smear is used to detect cervical cancer.

Anne, 36, had had regular periods all her life, “like clockwork, every 28 days.” After two pregnancies, she had a tubal ligation about three years ago. She and her husband recently divorced, and Anne was once again in the dating game.

Anne began seeing Brian about two months ago, and they had sex on their third date. They discussed STDs and condom use before becoming intimate and decided that since neither of them had had many sexual partners in their lifetimes, and they both “looked clean,” they didn’t need to use condoms. Anne wouldn’t become pregnant because her tubes had been tied.

Soon Anne began experiencing burning and itching on her labia, and intercourse was painful. She also noticed a fishy odor every now and then, and blood on the toilet tissue after she urinated. She talked it over with Brian, who had no symptoms and suggested that she see her gynecologist.

After a thorough examination, Anne’s gynecologist diagnosed trichomoniasis. Tests were performed for gonorrhea and chlamydia, and both were negative. Both Anne and Brian were surprised that Brian could have had the infection without symptoms. They were treated with antibiotics, and both of them decided to have tests for other STDs to be sure that they didn’t have any other diseases.

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Access to treatment for sexually transmitted infections is vital to one out of five teenagers. More than half of all students in grades nine to 12 have had sexual intercourse at least once. Nearly three-quarters have had sexual intercourse by grade 12. Each year, 3 million teenagers contract sexually transmitted infections. Many of these infections have no symptoms. Left untreated, they can cause serious health problems including infertility and cervical cancer.

Minors can be treated for sexually transmitted infections without parental consent in all states. Some states set no age limits. Minors can receive treatment at Planned Parenthood health centers, other family planning clinics, and “sexually transmitted disease clinics” sponsored by hospitals or local health departments.

Public health laws require health care providers to report certain infections, regardless of the age of the patient. Sexually transmitted infections that must be reported include syphilis, gonorrhea, chlamydia, herpes, HIV, and AIDS. In most cases, names are not reported. The information is used by public health officials to track the spread of infection.

Some urban public schools are linked to special health clinics to offer teenagers assistance with sexually transmitted infections, safer sex information, pregnancy concerns, and other health-related matters. There are now more than 500 of these across the country—some located in school buildings. They have helped reduce teen pregnancy and sexually transmitted infections.

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Is it safe to have sex with only one partner? Maybe. The ideal for many people is to do so. Women and men don’t need to worry about getting sexually transmitted infections:

• if neither partner ever had sex with anyone else

• if neither partner ever shared needles

• if neither partner was ever infected

Most of us have more than one sex partner during our lives. We may not plan it that way, but it happens. We may also get an infection from ne partner and carry it to another. The partners who gave it to us:

• may not have known they were infected

• may have hoped they wouldn’t infect us

• may not have been totally honest about their sexual histories

Some of us have only one partner, but our partner may “cheat.” Many women who got HIV from having sex thought they were their sex partners’ only sex partners.

We may want to give up safer sex because we’ve decided with our sex partners to have sex with no one else. But first we must be sure that neither partner is infected. Some infections, such as HIV, may take 10 years or more before symptoms develop. The early symptoms of many infections may go unnoticed. That’s why mutually monogamous partners must be sure to be tested for sexually transmitted infections before they give up safer sex.

Establishing trust in a sexual relationship is very important. We should be able to talk openly and honestly with our partners about our sexual histories and theirs. We should know whether our partners have had infections, and they should know about any infections we’ve had, before we agree to have unprotected sexual intercourse. Unfortunately, however, nearly one out of three people will lie about their feelings in order to have sex with someone else. A similar number will lie about their sexual histories. Only slightly fewer will lie about whether or not they have HIV!

When it comes to safer sex, we must rely on ourselves, not on our partners. Unless we have a very long, committed relationship that is built on open communication, we are the only people we are absolutely sure we can trust. Believing you are your sex partner’s only sex partner will not make it true. Here are some questions to think over:

• Do I know how my partner spends time away from me?

• Is my partner always open about everything with me—including the past?

• Does my partner get upset if I want to have a “serious” talk about our relationship?

• Does my partner keep secrets from me?

• Does my partner ever say, “I’m just going out,” or, “It’s none of your business”?

• Is my partner always respectful to me?

If you have a relationship that is secretive, has little open communication on serious health issues, and is lacking in equality and respect, you may very well be at risk for sexually transmitted infection.

We all want partners we can trust. The key is to make sure our partners earn our trust. We should never just give it away. Whether or not our partners have HIV won’t matter if we accept responsibility to protect ourselves. We shouldn’t take someone’s word for something so dangerous until we’ve been through an awful lot together—and even then we must be careful.

Women are at greater risk of getting an infection than men are. The vagina and rectum are more easily infected than the penis. A woman’s chance of being infected by a man with HIV is twice as great as a man’s chance of being infected by a woman with HIV.

Moreover, women generally have fewer symptoms than men. They are less likely to know that they are infected. Lots of damage can be done, even if there are no symptoms. Many women develop PID (pelvic inflammatory disease) because they don’t know they have gonorrhea or chlamydia. PID increases the risk of sterility and ectopic pregnancy.

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Since our interest in sexual behavior is in the context of its consequences for adolescent women, a pertinent question is: To what extent do sexually experienced adolescent women at–tempt to avoid pregnancy through use of contraception?

Although most sexually experienced unmarried adolescent women interviewed in 1971 had used contraception at some time, they took many chances. Over half of them had not used any contraception at their most recent coitus, and only two out of ten used contraception consistently. Younger sexually experienced women (fifteen- and sixteen-year-olds) were more likely to have never used contraception than older adolescents (seventeen- to nineteen-year-olds). Those adolescents who did use contraception generally began using it sometime after the first coitus. The earlier the age was at the first coitus the wider the gap was between first intercourse and first contraception. For most adolescent women, sex is a sometime thing and this may be an important factor in the low levels of consistent use of contraception. Sex is either unanticipated or it is not proper to go “prepared.” The data on the use of contraception as well as on the methods of contraception by frequency of intercourse were consistent with this line of interpretation. About forty-six percent of the women who had intercourse less than three times a month had used contraception at last intercourse compared to two-thirds of those who had intercourse six or more times a month. The choice of contraceptive methods also depended a great deal on the frequency of intercourse. Among the women who had not had intercourse in the month prior to interview, over half had used either the condom or withdrawal at their most recent experience, and only fourteen percent used the pill. In contrast, half the women with the highest frequencies of intercourse (six or more times a month) had used the pill at their last intercourse.

There is also considerable misconception about the risks of pregnancy. Seven out of ten sexually experienced women did not use contraception because they did not think they could become pregnant, because they had intercourse at a time of the month when they could not become pregnant, because they were too young to become pregnant, or because they had sex too infrequently to become pregnant. Some who believed they could not become pregnant because of the time of the month were correct in their judgment, but many were clearly misinformed about the risk of unprotected coitus.

One in ten of all fifteen- to nineteen-year-old women (married as well as unmarried) interviewed in 1971 had become pregnant before marriage. The overwhelming majority (about three-fourths) of the women indicated that the pregnancy was unintended. Yet, about nine out of ten of those who did not intend the pregnancy had not used contraception at the time of conception. A premarital pregnancy very often precipitates marriage, at least among whites. Over half the white young women who became pregnant premaritally married before the outcome of the pregnancy. The divorce rate among such marriages is reported to be much greater than among other marriages of young people (Schofield).

A comparison of the contraceptive use of sexually experienced, never-married women interviewed in 1971, with those interviewed in 1976 shows a dramatic increase in the proportion using contraception both consistently and at last intercourse. The increased use was seen for adolescent women of all ages and among both blacks and whites. In 1976, the younger respondents, those aged seventeen and under were more likely to have used contraception at last intercourse than were those over seventeen in 1971. Moderating this picture of improved contraceptive practice is the fact that there was also an increase in the proportion who never used contraception.

Along with the increased use of contraception there was a change in the methods of contraception. The pill was the most commonly used method by both blacks and whites and for all groups. About half the sexually experienced women in the 1976 survey named the pill as the method most recently used compared to less than a fourth in 1971. The condom, withdrawal, and douche, popular in 1971, were not as much in demand in 1976.

The increased permissiveness in sexual behavior has been paralleled by the increased effort at avoiding a premarital pregnancy, both by greater use of contraception and also by use of more effective methods. In 1976 the sporadic engaging in sex did not seem to be as great a deterrent to the use of contraception as it did in 1971. The greater use of oral contraception also suggests an increased willingness by adolescent women to be “prepared” for the occasion. Another factor in the greater use of birth-control pills may be that they are more readily available to young unmarried women now than they were in 1971.

Although the use of contraception has increased considerably, about half the sexually experienced adolescent women interviewed in 1976 had not used contraception at their first intercourse, and the gap between age at first intercourse and age at first contraception was wider in 1976 than it was in 1971. However, those who do not use contraception the first time but do so subsequently, tend to use more sophisticated methods like the pill and the IUD. In 1976, of the women who had not used contraception at their first intercourse but did so subsequently, six out of ten used the pill or IUD as their first method, and only three out of ten used the condom or withdrawal. In contrast, six out of ten women who used contraception at their first intercourse used the condom or withdrawal. This difference in the quality of contraception between those who delayed first use and those who did not was not a matter of age at the time contraception was first used or of experience with pregnancy, although pregnancy was frequently an incentive to more effective contraception.

Although the increasing use of the pill and the IUD among adolescent women should help prevent undesired pregnancy, the desirability of early and continued use of these contraceptives is questionable because of known and suspected risks of serious side effects. A question may also be raised about the increased prevalence of venereal diseases among adolescents which seems to coincide with the decline in use of the condom. The detrimental effects of the present contraceptive practices of adolescents, combined with the likelihood that the prevalence of sexual intercourse will continue to increase, suggest a need for the development of contraceptives suitable for young adolescents.

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Erotic awakening is of two kinds, autoerotic and sociosexual or interpersonal erotic. Since Freud and Kinsey, if not before, we have been aware that autoeroticism—erotic gratification obtained from the self without the participation of another person—can be present from the first year of life. Interpersonal awakening comes at different ages for different persons depending on biological-response capacity and maturation, temperamental tendencies (cuddler or noncuddler, for instance), and experience.

Erotic awakening is a vague and mystical concept. What it means is that someone who previously lacked the capacity for erotic experience now possesses that capacity. One has “new life” so to speak; something is there that was not there before. Puberty is sometimes looked upon as establishing the biological-response base for the first erotic event. But we know that the capacity for at least the rudiments of erotic awakening is present from birth or shortly thereafter. Erotic awakening comes when that which is “dormant” or “asleep” is aroused to action. The experience may be feeding at the breast of the mother, being handled or caressed at a tender age, a first kiss, or later “falling in love,” first coitus, or first coitus with orgasm. Some parents consciously or unconsciously treat their offspring as though the erotic capacity were present from birth, as indeed it is. Such parents act as though what they do to and with the infant or child will affect the time at which they experience their erotic awakening and that after awakening they will in fact be different. This belief no doubt explains much of the style of infant and child care that mothers give their offspring, starting with the decision to suckle or not to suckle the infant.

Besides direct erotic encounters with peers, there are many events which stimulate the growth of sexual curiosity and aid in sexual awakening of the infant or child. Among these events are the presence of a puppy in the home, seeing a litter of kittens for the first time, seeing members of the family in the nude, noticing the differences in men’s and women’s bodily characteristics, seeing the changes that occur in a pregnant woman, the presence of a new baby, or a chance bit of information concerning the coming of babies or other sexual events.

Despite such apparent sexual precocity, children aged three to four have some difficulty learning that there are genital differences between the sexes. They do not appear to form clear concepts of genital differences until ages five to seven. From a sample of children mostly from a lower socioeconomic level, whose parents indicated that many of them had not been told about basic anatomical differences, Conn, and Conn and Kanner, were able to elicit knowledge of genital differences from only fifty percent of children ages four to six years and from seventy-two percent of children ages seven to eight. Among children of parents with more formal education, Butler found a similar degree of ignorance among children of four to five years of age. Although fifteen of seventeen children had been informed by their parents of anatomical differences, Butler was able to elicit awareness of genital differences from only five of the fifteen children. Ketcher found in a study of 226 three- to nine-year-olds that children most easily make sex differentiations based on the clothing worn by each sex, followed by differentiation based on hair styles, and lastly by observing differences in genitalia and breasts. Age seemed to be the most important factor in ability to differentiate between the sexes, and younger girls were better than younger boys in this regard. Children report that before their first witnessing they had assumed that the genitals of all people were alike.

The young child who has been told which male and female attributes are used in producing a baby still remains perplexed as to how the elements come together. Even children who have observed parental coitus do not find this sufficient to create an articulated sexual image of the mother or father, whatever else it might do.

By age five, children are easily aware of most of the non-coital content of the marital relationship—cooking, cleaning house, caring for children, going to work. They practice many of the marriage and family roles through “playing house.” They also have a good idea of the field of future eligible mates, opposite-sex peers of the same generation but not of the same family. Broderick found that the majority of five-year-olds he studied were already committed to their own eventual marriages. This majority increases through each age group throughout childhood.

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When a child is born, the program of sexual development and differentiation, previously controlled by genetic, hormonal, and constitutional events, passes to the behavior environment. There, social and cultural influences govern the continuing development and differentiation of psychosexual functioning. The principle of sexual bipotentiality, which pertains to reproductive anatomy and to the neurosexual centers located in the hypothalamus, applies also to psychosexual and sociosexual behavior. The social program of rearing resolves behavioral bipotentiality as masculine or feminine in early life.

In the first two years of life, behavioral components of adult sexual behavior begin to emerge, and the sociosexual and psychosexual components of adult eroticism are initiated. Childhood constitutes a period of preparation and rehearsal of the part-responses that are eventually chained together into adult sexual pair-bonding. It is characteristic of mammals for behavior segments to appear and to be rehearsed and practiced prior to their functional integration into the life cycle. Sexual behavior is no exception to this rule, judging from observations of animals, from accounts of primitive societies in which childhood sex play and sex rehearsals are permitted, and from the retrospective accounts of human adults.

There are three phases of psychosexual development in the neonatal and infancy period. The first, common to both sexes, is related to pair-bonding of the infant and the parent; it begins in the delivery room with parental participation in childbirth. The second comprises genital activity rehearsals, also present at or even before birth, and clearly observed in the genitopelvic responses of the male neonate. The third is a masculine and feminine differentiation phase which begins in the delivery room with the announcement of the infant’s sex.

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No one can explain it, but in the past decade well-to-do middle-aged men have begun falling victim to a previously rare form of cancer. This has happened particularly to white men. There has been no change in the incidence of this cancer among Asian and black men or among women.

It’s a cancer thought to be directly related to reflux – the surging up of stomach acid into the food pipe. The tragedy of this adenocarcinoma of the oesophagus or gullet is that it is lethal. Only 10 per cent of sufferers survive for more than 5 years.

Mysteriously, the incidence among white men living in Western societies is increasing at a rate of 10 per cent a year. In the past, a different kind of gullet cancer was predominant. About 20 years ago people tended to get squamous-cell carcinoma of the oesophagus, which was strongly related to smoking and the ingestion of alcohol. Now, as squamous-cell carcinoma levels have plateaued and even fallen off in men, the incidence of adenocarcinoma in men has begun increasing at a frightening pace. It is now occurring in three Australian men in every 100 000, and is particularly prevalent among the well-nourished and well-to-do.

The gullet is lined with a kind of skin, so it is understandable that squamous-cell carcinoma, which is a skin-like cancer, can grow there. It is more difficult to understand how adenocarcinoma, which is a gland-like cancer, can develop there.

Adenocarcinoma has a glandular cell structure and usually grows in glands such as those in the stomach, the pancreas and the bowel. It is abnormal to find it in the gullet. A healthy man would have no glandular tissue in his oesophagus.

It is thought that long-standing severe reflux starts the process that ultimately leads to this cancer. Of course, most men with reflux never develop it, but all those who do have it have a history of reflux.

Reflux occurs when the contents of the stomach get washed back up the gullet because the valve between the gullet and the stomach is not efficient enough to keep the acid and food in the stomach. It is thought that over the years the acid burns the skin lining off the lower end of the gullet and is gradually replaced by a different kind of lining, which is more resistant to acid.

This new lining is made up of gastric-type cells, which behave as if they were in the stomach. It looks like the gastric cells have broken out of the stomach and begun growing up the gullet. When this happens, a man is said to have a condition known as Barrett’s oesophagus. There are thousands of men out there with reflux, and it is not known why some develop a Barrett’s lining and others don’t.

Barrett’s is a precursor to this cancer, and it is not understood why some people with Barrett’s develop the cancer and others do not. When adenocarcinoma grows in the Barrett’s lining, it looks and acts like gastric cancer.

It is thought that a Barrett’s lining takes decades to develop.

When, for example, it is found in a 50-year-old man, there is characteristically at least a 20-year history of reflux.

One difficulty with Barrett’s is that men are unaware of it. It does not show up with a barium meal and X-ray and can only be found through an endoscopic examination. Because the lining has changed, it copes much better when acid is washed past, and the man may feel less pain or discomfort. With a Barrett’s oesophagus, reflux may effectively become a silent condition.

If, after a long time, a man notices a change in his reflux pattern, it could be a sign of Barrett’s. If he has had persistent reflux for 20 years and then, in the absence of new medication or a changed diet, his reflux seems to fade, he should be checked for the condition.

Tests show that men with Barrett’s have more acid in their gullet but that it does not seem to hurt as much. They also show that the valve between their gullet and stomach operates at a much lower pressure, which makes it less efficient. Usually, these men also have a hiatus hernia, which occurs when a portion of the stomach protrudes upwards through the diaphragm. This is a major factor in the valve losing pressure. Men commonly develop this hernia as they age.

At any one time, about one-third of the male population will have abnormal reflux. About 10 per cent of this third will develop Barrett’s. Of them, 10 per cent may develop adenocarcinoma of the oesophagus.

In New South Wales, about 250 people die from this cancer every year, and the vast majority of them are men. Some specialists say an effective preventive measure against Barrett’s and reflux is a hiatus hernia repair. The theory is that the hernia leads to valve weakening, which leads to reflux, which leads to Barrett’s, which leads to the cancer.

With keyhole surgery, the hernia can be repaired in an operation requiring just 2 days in hospital. Surgery for adenocarcinoma of the oesophagus is more drastic than open-heart surgery and involves removing part of the lower oesophagus and part of the upper stomach, then using the remaining stomach to form a tube to reconstitute the plumbing. During this operation, appropriate lymph nodes are also removed. Surgery certainly appears to improve men’s chances of surviving for a number of years.

Affluent men should be alert to a change in their digestion patterns. If food starts to stick or the man has difficulty swallowing or needs to drink water to get food down, he should see his doctor.

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