News Sexual Health

CDC Confirms Rare Case of Woman-to-Woman HIV Transmission

Martha Kempner

The CDC confirmed a case of sexually transmitted HIV from one woman, who was diagnosed previously but stopped receiving antiretroviral treatment in 2010, to her female partner. While rare, this case should remind all of us that safer sex remains important.

The Centers for Disease Control and Prevention (CDC) confirmed this week, in its publication Morbidity and Mortality Weekly Report, that a woman in Texas became infected with HIV through sexual contact with her female partner.

Sexually transmitted HIV between two women has always been considered possible, but is very rare and often hard to prove, as women may have engaged in other behaviors that carry more risk, such as heterosexual sex or sharing needles for intravenous drug use. The woman in this case, who became infected in 2012, had not had heterosexual sex in over ten years, and had only three female partners in the last five years and one partner in the six months prior to infection. In addition, she did not use intravenous drugs, and had not recently gotten a piercing, tattoo, blood transfusion, or organ transplant, which are all known routes of infection. More importantly, the CDC explains that the 46-year-old woman “had a virus virtually identical to that of her female partner, who was diagnosed previously with HIV and who had stopped receiving antiretroviral treatment in 2010.”

HIV is present in bodily fluids such as blood, semen, vaginal secretions, and breast milk. The virus can be transmitted when these fluids come into contact with a sore, a cut, a wound, or mucous membranes in an uninfected person. HIV cannot be transmitted through unbroken skin such as that on a person’s hand. This is why certain sexual activities are riskier than others—unprotected vaginal and anal intercourse are riskiest, for example, because the vagina, anus, and urethra are lined with mucous membranes. The skin around these areas is also more delicate and can tear more easily. But, the risk is not the same for both partners—the receptive partner is at increased risk because semen comes into contact with mucous membranes and any cuts and sores that may be present. Moreover, semen often stays in the vagina or anus for some time, giving it more opportunity to enter the blood stream.

Sexual behaviors between two women, which might include mutual masturbation, oral sex, rubbing genitals together, or penetration with fingers or sex toys, among other things, carry less risk of body fluids coming into contact with mucous membranes or blood. As such, it has always been considered safer, and women who have sex exclusively with other women have been thought of as very low risk for sexually transmitted HIV. While this remains true, this case should remind us that though rare, women-to-women transmission can happen.

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The women in this case told CDC investigators that they frequently had sex that was rough enough to cause one or the other of them to bleed. They also shared sex toys back and forth, and had unprotected sex during menstruation. All of these things increased the risk that the HIV-positive woman could transmit the virus to her partner. In addition, the HIV-positive partner had stopped taking her antiretroviral drugs. Had she kept taking them, she likely would have had less virus in her blood and been less likely to transmit it to her partner.

This case should also remind all people, regardless of the sex of their partners, that there are simple steps couples can take to reduce their risk of transmitting HIV. Using condoms is the most important thing that couples engaging in penetrative sex can do to prevent HIV and other sexually transmitted diseases. Condoms can also be used to cover sex toys, and then changed before the toy is used on a different person. This can prevent germs and fluids from being passed back and forth. If a couple doesn’t have a condom, they should wash the sex toy in between uses. Minimizing the chance of blood and cuts—either by being gentler or using lubricant—can also cut down on risk. Finally, in couples where one partner is known to be HIV-positive, continuing antiretroviral treatment can reduce the amount of virus in that person’s blood, making it less likely that he or she transmits HIV.

Though this case should by no means cause a panic, it should remind us all that practicing safer sex is always a good idea.

Commentary Sexual Health

Know Your Status: Working to Destigmatize Routine STI Screening

Dr. Megan L. Evans

April marks STD Awareness Month and the Get Yourself Tested campaign: There is no time like the present to check your status, discuss testing with your sexual partner, and talk about safer sex with your provider.

“Would you like screening for sexually transmitted infections today?”

As an obstetrician and gynecologist, it is a question I ask multiple times a day to the patients I see in my office. Most patients think about my question for a moment, maybe look down at the floor or nervously check their smart phone, and then say “sure!” The question is a simple one but it is obvious that, for some patients, sexually transmitted infection (STI) testing carries the weight of stigma or embarrassment.

Although the Centers for Disease Control and Prevention (CDC) recommends routine STI testing for all women under the age of 25, STI cases in all age groups are on the rise, as indicated in a recent report. In 2014 alone, there were approximately 350,000 new cases of gonorrhea and more than 1.4 million new cases of chlamydia. Unfortunately, many of these infections may go untreated or undiagnosed and can have detrimental health effects, particularly among women who can experience disseminated infections requiring hospitalizations, infertility, and pelvic inflammatory disease.

So, whether they are age 17 or 45, in the women’s clinic or the community health center, everyone I see is offered the opportunity—and encouraged—to check their STI status.

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And it’s not just women or young people who should get tested. In February, the CDC released a study finding that half of gay and bisexual Black men and a quarter of gay and bisexual Latino men will be diagnosed with HIV in their lifetimes. As a health-care provider, I believe that encouraging everyone to know their STI status, regardless of their sexual orientation or gender identity, can not only prevent serious medical conditions, but can encourage safe and healthy sexual practices.

It’s important, however, for everyone to understand: Both patients and providers have an important role to play in destigmatizing routine STI screening.

We as physicians can do a better job at creating a safe environment for patients to ask questions about sex and sexuality. One study suggested that when physicians do discuss sexual health issues with adolescents, the discussion averages 36 seconds. When the topic of sexuality is discussed in the health-care setting, fewer than 10 percent of young people reported receiving information on STIs and HIV from their provider.

Surveys of U.S. teens and young adults show that these group, which are greatly affected by STIs, understand the importance of routine testing. One survey found that 81 percent of youth reported thinking that people who get STI testing are taking care of their sexual health; 58 percent said they are responsible partners, and 56 percent said they do it regularly as part of their routine health care. When asked by a sexual partner about getting STI screening together, 78 percent said they would be glad a test was suggested and 89 percent thought it reflected their partner being responsible.

However, significant barriers may exist that are keeping adolescents and young adults from knowing their STI status, like access to care. Though all 50 states allow minors to get STI screening without parental notification, young people may face barriers to accessing clinics in general or fear their parents will be notified they are requesting STI services (as at least 18 states allow physicians to do so).

Research shows us that confidentiality and of course stigma can exist around getting tested, which may prevent a person—especially a young person—from knowing their STI status. A 2014 study published in JAMA Pediatric reported that one-third of teens did not talk about sex or sexuality during their annual visits with their health-care provider and many teens felt uncomfortable talking with their provider about topics including sexuality and STIs.

As a patient, you should not hesitate to bring up questions about STI screening as well as your general health with your provider. If you do feel uncomfortable asking these questions and requesting screening with your provider, you can always go to a local Planned Parenthood or other health centers that openly offer screening.

April marks STD Awareness Month and the Get Yourself Tested campaign spearheaded by a partnership between the Kaiser Family Foundation, MTV, Planned Parenthood, and other organizations. There is no time like the present to check your status, discuss testing with your sexual partner, and talk about safe sex with your provider. Whether getting tested with a primary care physician, an OB-GYN, or at a local health center, taking this step is an important part of taking care of your health and is generally quick and easy. A routine STI check can be completed by a simple urine test and blood test in most health centers.

As providers, asking about STI screening should be routine and offered to all patients. This helps to open the conversation to your patients about their sexuality and may prompt further discussion about safer sex. The message is a simple one: getting tested is part of staying healthy and taking care of your body.

Remember that sexuality is a natural and healthy part of life and is an important component of physical and emotional development. Everyone deserves good sex: sex that is consensual, healthy, pleasurable, safe, and respectful. Having a healthy sexuality also includes knowing your STI status.

Full disclosure: Dr. Megan Evans is on the Young Friends Steering Committee of Planned Parenthood. 

Commentary Sexual Health

Of Ducks and Women: For Us, Sex Should Not Hurt

Martha Kempner

The Internet has been abuzz with discussions of painful sex among our animal friends after astrophysicist Neil deGrasse Tyson mistakenly suggested that any species for whom sex hurt would already be extinct. Unfortunately, many women know all too well that on this subject, deGrasse Tyson was way off the mark.

The Internet has been abuzz with discussions of painful sex among our animal friends after astrophysicist Neil deGrasse Tyson mistakenly suggested in a tweet, “If there were ever a species for whom sex hurt, it surely went extinct a long time ago.” Twitter users and journalists leapt at the chance to tell one of the world’s leading astrophysicists that he was wrong about biology, and that there are a lot of members of the animal kingdom for whom the act of mating doesn’t appear to be all that pleasant.

Take the duck. Apparently, a female duck’s vagina corkscrews in the opposite direction from the corkscrew on the male’s penis, which may help her ward off unwanted advances but seems as if it could make desired sex uncomfortable for both of them. And ducks aren’t the only ones for whom copulation may be painful—to name just a few other examples, a male cat has barbs on his penis which can scrape his partner’s vagina, a male bed bug inseminates his female partner by piercing a hole in her abdomen, and female praying mantises eat their male partners when the deed is done.

It seems that humans are among the lucky ones for whom sex can feel so good that we do it more often for recreation than we do for procreation. But humans, women in particular, can feel pain during penetrative sex too. In fact, the American Congress of Obstetricians and Gynecologists notes that nearly three out of four women have felt pain during intercourse at some point during their lives. Unfortunately, sex education classes in schools often spend very little time talking about pleasure, and women especially—who frequently grow up around whispers of how much the “first time” hurts—may think they just have to put up with a little unwanted pain or discomfort during sexual experiences. (While some people can experience penile pain, often as the result of an infection, it generally is not related to sexual behavior in the same way.)

Sex should not hurt. If it does, look at that as your body’s way of sending you a signal that something is not quite right.

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Before we get into specifics, however, it’s important to acknowledge some caveats.

First, it is important to note that we are talking about issues that lead to pain during consensual sexual activity. The issues involved during and after sexual assault or any kind of nonconsensual sex are very different, and we’re not going to attempt to address them here. If you suspect those circumstances might apply to you, you may want to consult your health-care provider, a mental health expert, or the Rape, Abuse & Incest National Network, which operates phone and online hotlines.

Also, this is not meant as professional medical advice. This article can give you ideas from my perspective as a sexuality educator, but it can’t give you a diagnosis. Again, only your health-care provider can do that.

With that in mind, there are many possible reasons that sex could be less than fun.

It Could Be Desire

Sex is a physical activity, to be sure, but there is a big mental component as well. Your state of mind matters. If you feel guilty, embarrassed, afraid, or even just distracted by what’s going on in the rest of your life, you might not be able to relax and become aroused. Stress and exhaustion can also get in the way of arousal, as can relationship issues, including an unequal interest in sex.

Painful sex can result from any one of these emotional factors, or a combination thereof. Take a minute to try and figure out if anything was bothering you before or during sex, and what you might be able to change so that this doesn’t happen again. It’s always good to start by talking to your partner and seeing if you can figure it out together. If the issue is ongoing, you might consider talking to a mental health expert or a sex therapist.

It Could Be Technique

No one wants to be told that they’re “doing it wrong,” and, of course, there is no right or wrong way to “do it.” That said, vulvas and vaginas are sensitive, and it is possible for them to be touched in a way that feels, well, not great. Every person is different: A technique that may make one partner feel fantastic may just be irritating to another. The same goes for sexual positions—what one person likes may make another one uncomfortable.

Here, communication is important. Give your partner some ideas and advice. Subtle clues like moaning when they get it right are great, but you may have to be more directive. It’s okay to ask someone to speed up, slow down, or move a little to the left. Be gentle and funny if you think that will help, but don’t be afraid to say what you like.

Of course, in order to do this, you have to know what you like. If your partner is game, this can be a fun team project, but spending some quality time figuring it out on your own (i.e., masturbating) can also be very useful.

It Could Be Lubrication (Or a Lack Thereof)

Blood rushes to the vagina upon arousal in a process called vasocongestion, which in turn causes the vagina to produce lubrication. This wetness helps protect against chafing and irritation when the vulva is touched or the vagina is penetrated. Without sufficient lubrication, sexual activity can be uncomfortable.

It can be helpful to figure out why there isn’t enough lubrication. Sometimes it’s because you haven’t gotten turned on enough, and spending just a little more time on foreplay could be all that’s necessary. It could also be the result of hormone changes—dryness is common in women who are going through or have gone through menopause, for instance—or certain medications. Or it could just be the natural state of your body; some people just produce less lubrication than others.

Regardless of the cause, dryness issues can be fixed by using lubricants. The truth is almost everyone can benefit from a little extra lube. A quick trip to the pharmacy will show just how many options there are when it comes to lube—from the tingly to the flavored to the vegan. Try one or try them all.

Just a few quick notes: If you’re using condoms for birth control or the prevention of sexually transmitted infections (STIs), avoid oil-based lubes because oil breaks down latex—intead, use water-based or silicone-based lubes. Also, if you’re using sex toys, you may also want stick to water-based lubes, because silicone can cause some of them to deteriorate. Read the label of whatever lube you choose; it should let you know what is and isn’t compatible.

It Could Be Medical

There are also a number of medical explanations for what might be behind the discomfort. The catch-all phrase for things that cause inflammation of the vagina—and the itching, burning, and pain during sex that goes with it—is vaginitis. STIs cause vaginitis, but so do other things like yeast infections. The truth is that the vagina has a pretty delicate system of naturally occurring bacterial and fungi that are usually kept in balance. When this equilibrium is disrupted—which can happen when a woman is taking an antibiotic, uses a fancy new soap, or has even just has sex—things can get uncomfortable.

Pain upon penetration can also be caused by certain gynecological problems, such as endometriosis (an inflammation of the lining of the uterus), pelvic inflammatory disease, or cysts on the ovaries. Many of these medical problems that cause pain are easily treated once diagnosed.

For some individuals, however, vulvar and vaginal pain can become chronic and may not be limited to during sex. These people are often diagnosed with vulvodynia—a term that basically means painful vulva. There are different theories about what causes this condition, and there isn’t one method that seems to work for everyone who has it. But there are treatments: Some individuals respond to certain medications that are thought to interrupt the pain signals the body is sending, and others do well with physical therapy and biofeedback.

The purpose here is not to give an exhaustive list of conditions that lead to painful sex, but to say that pain during intercourse is often a sign of an underlying medical problem. If it persists, you should get checked out.

Whatever You Do, Don’t Close Your Eyes and Think of England

In previous generations, women were taught not to expect sexual pleasure—sex was something for men to enjoy and women to endure. Thankfully, we now know enough to consider this absurd (not to mention sexist and infuriating). And yet, some vestiges of these views seem to have hung around and left some women with the impression that a little bit of pain during sex is just to be expected.

It’s not.

The basic rule is pretty simple. If your vulva or vagina itches, burns, or hurts—get it looked at by a health-care professional. If you have a bump or a sore—get it looked at by a health-care professional. If it hurts when someone touches it or if penetration is painful—go see a health-care professional. If you’ve ruled out physical ailments—consider talking to a therapist about what else might be going on. And if the pain becomes chronic—go back and tell that professional it is still hurting.

Don’t just grin and bear it.

We are not ducks, we are not bed bugs, and we are not antechinuses (a marsupial whose males have so much sex they start to bleed internally and go blind). We are human beings, and we deserve sex that is not just pain-free, but feels really good.