Solved by verified expert:For the following questions, you are required to thoroughly answer the reflection questions below and clearly connect the information to the learning objectives. The summaries should show critical analysis and synthesis of the information in a way that demonstrates good understanding of the material presented. Each question should be 5 paragraphs (containing a minimum of 4-6 sentences each) in length. So around 15 paragraphs total, and they should be written in correct APA style. Please use your own words and use in-text citation when you cite any sources.😀 Question #1After reading the “Think About It” article (in the attachment , it is a one page article) related to female genital cutting in the textbook, and viewing the two videos on FGC, please answer the “Think Critically” question:1. Should female genital cutting be eliminated worldwide, or should it be permitted in countries where it is an important custom?2. Which is the better term: female genital cutting or female genital mutilation? Why?3. Does FGC violate the human rights of girls and women? If so, in what ways? If not, why? question #2List the signs and symptoms of five (5) STIs that you learned about from the textbook (which in the attachment, Chapter 15), video, or other scholarly source.What would be your most important concern if you just learned you had an STI? Who would you tell? What resources would you need? And where could you go to get help? question #3After reading the article related to “date rape” (check the below attachment) and watching the video, please answer the “Think Critically” questions:1. How common is the use of rape/acquaintance rape drugs on your campus? In what type of situations does it occur?2. What can a person do to avoid being vulnerable to date/acquaintance rape?


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The STI Epidemic 483
Principal Bacterial STIs 493
Principal Viral STIs 500
Vaginal Infections 506
Other STIs 508
Ectoparasitic Infestations 509
STIs and Women 510
Preventing STIs 511
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“Up to this date, I have
slept with about
thirteen men. My most
recent ‘wake-up call’
was from a threat
from a prospective
partner and from a
human sexuality
course. I took a test
for HIV; the result was
negative. However, I did get infected and passed on genital warts
to my ex-boyfriend. I simply pretended that I had never slept with
anyone else and that if anyone had cheated it was him. It never
fazed me that I was at such a risk for contracting HIV. My new
resolutions are to educate my family, friends, and peers about sex,
take a proactive approach toward sex with prospective partners,
and discuss sex openly and honestly with my mother.”
—23-year-old female
“My partner and I want to use a condom to protect ourselves
from STIs. But I feel inadequate when we are intimate and he
cannot keep an erection to put a condom on. I feel too embarrassed for him to discuss the situation. So, we both walk away a
O rose, thou art sick!
The invisible worm
“ That
flies in the night,
In the howling storm,
Has found thy bed
Of crimson joy,
And his dark secret love
Does thy life destroy.
—William Blake

Chapter 15
bit disappointed—him because he could not stay erect and me
because I did not take the time or have the courage to help him.
I think if he masturbated with a condom on it would help him
with his performance anxiety problem.”
—22-year-old female
“STIs and HIV are precisely the reason I exercise caution when
engaging in sexual activity. I don’t want to ever get an STI,
and I’d rather never have sex again than have HIV.”
—24-year-old male
“Why do males often convince women to have sex without proper
protection? I don’t understand this because there is always a risk of
getting an STI. I know that women think about this just as often as
men do, but why is it that men do not seem to care?”
—21-year-old female
“I am usually very careful when it comes to my sexual relations and
protecting myself from STIs, but there have been a couple of times
when I’ve drunk a lot and have not practiced safe sex. It scares me
that I have done things like that and have tried to make sure it
doesn’t happen again. STIs are just a very uncomfortable subject.”
—27-year-old male
he term “sexually transmitted infections” (STIs) refers to more than
25 infectious organisms passed from person to person primarily through
sexual contact. STIs were once called venereal diseases (VDs), a term derived
from Venus, the Roman goddess of love. More recently, the term “sexually
transmitted diseases” (STDs) replaced “venereal diseases.” Actually, many
health professionals continue to use “STD.” However, some believe that “STI”
is a more accurate and less judgmental term. That is, a person can be infected
with an STI organism but not have developed the illness or disease associated
with the organism. So, in this book, we use “STI,” although “STD” may
appear when other sources are cited.
There are two general types of STIs: (1) those that are bacterial and curable,
such as chlamydia and gonorrhea, and (2) those that are viral and incurable—
but treatable—such as HIV infection and genital herpes. STIs are a serious
health problem in our country, resulting in considerable human suffering.
In this chapter and the next, we discuss the incidence (number of new
cases) and prevalence (total number of cases) of STIs in our country particularly among youth, the disparate impact of STIs on certain population groups,
the factors that contribute to the STI epidemic, and the consequences of STIs.
We also discuss the incidence, transmission, symptoms, and treatment of the
principal STIs that affect Americans, with the exception of HIV/AIDS, which
is the subject of Chapter 16. The prevention of STIs, including protective
health behaviors, safer sex practices, and communication skills, is also addressed
in this chapter.
Sexually Transmitted Infections
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The STI Epidemic
The federal Institute of Medicine (IOM) characterizes STIs as “hidden epidemics
of tremendous health and economic consequences in the United States,” adding
that “STDs represent a growing threat to the nation’s health and national action
is urgently needed.” The IOM notes that STIs are a challenging public health
problem because of their “hidden” nature. The IOM adds that “the sociocultural
taboos related to sexuality are a barrier to STD prevention” (Eng & Butler, 1997).
The “silent” infections of STIs make them a serious public threat requiring greater
personal attention and increased health-care resources.
STIs: The Most Common Reportable Infectious Diseases
STIs are common in the United States, but identifying exactly how many cases
there are is impossible, and even estimating the total number is difficult. Often,
an STI is “silent”—that is, it goes undiagnosed because it has no early symptoms
or the symptoms are ignored and untreated, especially among people with limited
access to health care. Asymptomatic infections can be diagnosed through testing,
but routine screening programs are not widespread, and social stigmas and the
lack of public awareness about STIs may result in no testing during visits to
health-care professionals. And even when STIs are diagnosed, reporting regulations vary. Only a few STIs—gonorrhea, syphilis, chlamydia, hepatitis A and B,
HIV/AIDS, and chancroid—must be reported by health-care providers to local
or state health departments and to the federal Centers for Disease Control and
Prevention (CDC). But no such reporting requirement exists for other common
STIs, such as genital herpes, human papillomavirus (HPV), and trichomoniasis.
In addition, the reporting of STI diagnoses is inconsistent. For example, some
private physicians do not report STI cases to their state health departments
(American Social Health Association [ASHA], 2006a; CDC, 2011f). In spite of
the underreporting and undiagnosed cases, several significant indicators illustrate
the STI problem in the United States:
■ STIs are the most common reported infectious diseases in the United

States. In 2008, STIs represented four of the five most frequently
reported infectious diseases (CDC, 2010d) (see Figure 15.1).
An estimated 19 million new STI cases occur each year (CDC, 2011g).
STIs negatively impact the lives of more than 65 million Americans
(CDC, 2008g).
By age 25, 1 in 2 young persons will acquire an STI (Cates, Herndon,
Schulz, & Darroch, 2004).
More than one half of sexually active men and women will become
infected with an STI at some point in their lives (CDC, 2011f ).
One in four teenage girls (3.2 million) in the United States is infected
with at least one of the most common STIs: HPV, chlamydia, genital
herpes, or trichomoniasis (CDC, 2008h).
Who Is Affected: Disparities Among Groups
Anyone, regardless of gender, race/ethnicity, social status, or sexual orientation, can
get an STI. What people do—not who they are—exposes them to the organisms
that cause STIs. Nevertheless, some population groups are disproportionately
The STI Epidemic

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• FIGURE 15.1
Selected Notifiable Diseases,
United States, 2008. (Source:
Centers for Disease Control and
Prevention, 2010d.)
900,000 1,000,000 1,300,000
Number of cases, 2008
*Infection with the Salmonella bacterium that causes diarrheal illness.
affected by STIs; this disparity reflects gender, age, and racial and ethnic differences
(CDC, 2011g).
Gender Disparities Overall, the consequences of STIs for women often are
more serious than those for men. Generally, women contract STIs more easily
than men and suffer greater damage to their health and reproductive functioning.
STIs often are transmitted more easily from a man to a woman than vice versa.
Women’s increased likelihood of having an asymptomatic infection results in a
delay in diagnosis and treatment (ASHA, 1998a; CDC, 2011f).
A kind of “biological sexism” means that women are biologically more susceptible to infection than men when exposed to an STI organism (Hatcher
et al., 2007). A woman’s anatomy may increase her susceptibility to STIs. The
warm, moist interior of the vagina and uterus is an ideal environment for many
organisms. The thin, sensitive skin inside the labia and the mucous membranes
lining the vagina may also be more receptive to infectious organisms than the
skin covering a man’s genitals. The symptoms of STIs in women are often very
mild or absent, and STIs are more difficult to diagnose in women due to the
physiology of the female reproductive system. The long-term effects of STIs for
women may include pelvic inflammatory disease (PID), ectopic pregnancy,
infertility, cervical cancer, and chronic pelvic pain, as well as possible severe
damage to a fetus or newborn, including spontaneous abortion, stillbirth, low
birth weight, neurological damage, and death (CDC, 2011f ).
Lesbian and bisexual women may also be at risk for STIs. A nationally representative study found the rates of self-reported genital herpes and genital warts
to be 15–17% among self-identified bisexual women and 2–7% among selfidentified lesbian women (Tao, 2008), both groups aged 15–44. Another study
of lesbian and bisexual women found that many underestimated their risk for
STIs, had limited knowledge of potential STI transmission, and reported little
use of preventive behaviors with female partners, such as washing hands, using
rubber gloves, and cleaning sex toys (Marrazzo, Coffey, & Bingham, 2005).
According to a study conducted in Sydney, Australia, women who had sex
with other women had a higher rate of bacterial vaginosis (BV) than heterosexual
women. Among the women who had sex with other women, 93% reported

Chapter 15
Sexually Transmitted Infections
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previous sexual contact with men; they had a median (the numerical value in the
middle of the upper half and lower half of a group of numbers) of 12 lifetime
male sexual partners, compared with 6 lifetime partners for the heterosexual
women. Thus, lesbian women may not be free of STI risk because many women
who have sex with other women and self-identify as lesbian also have sex with
men during their lifetime (Fetters, Marks, Mindel, & Estcourt, 2000). A study
of 35 lesbian and bisexual women aged 16–35 found that BV was associated with
reporting a partner with BV, vaginal lubricant use, and the sharing of sex toys
(Marrazzo, Thomas, Agnew, & Ringwood, 2010). Studies have found that women
who had sex with both men and women had greater odds of having acquired a
bacterial STI and had more HIV/STI behavioral risk factors than women who
had sex only with men (Bauer, Jairam, & Baidoobonso, 2010; Kaestle & Waller,
2011; Mercer et al., 2007; Scheer et al., 2002). A case study found that femaleto-female transmission of syphilis occurred through oral sex (Campos-Outcalt &
Hurwitz, 2002).
Surveillance data on several STIs suggest that an increasing number of men
who have sex with men (MSM) are acquiring STIs. For example, in recent
years, MSM have accounted for an increasing number of estimated syphilis
cases in the United States. In 2010, 67% of syphilis cases in the U.S. were
among MSM (CDC, 2011f ). (HIV/AIDS data for men who have sex with
men will be presented in Chapter 16.)
Age Disparities Compared to older adults, sexually active young adolescents,
12 to 19 years old, and young adults, 20 to 24 years of age, are at higher risk
for acquiring an STI. About one half of new STI cases are among individuals
aged 15–24 although they comprise only about one quarter of the sexually active
population (CDC, 2011f; Weinstock, Berman, & Cates, 2004). Young people
are at greater risk because they are, for example, more likely to have multiple
sexual partners, to engage in risky behavior, to select higher-risk partners, and
face barriers to accessing quality STI prevention products and services (CDC,
2007e, 2011f ).
Racial and Ethnic Disparities Race and ethnicity in the United States are
Rate (per 100,000 population)
STI risk markers that correlate with other basic determinants of health status,
such as poverty, access to quality health care, health-care-seeking behavior, illegal
drug use, and communities with high prevalence of STIs. STI rates are higher
among racial and ethnic minorities. (See Figures 15.2 and 15.3 for rates of two
STIs—chlamydia and gonorrhea—by race/ethnicity, 2000–2009.) Social factors,
• FIGURE 15.2
American Indians/Alaska Natives
Asians/Pacific Islanders
Rates of Chlamydia by Race/
Ethnicity, United States,
2000–2009. (Source: CDC, 2010e.)
The STI Epidemic

• FIGURE 15.3
Rates of Gonorrhea by Race/
Ethnicity, United States,
2000–2009. (Source: CDC, 2010e.)
Rate (per 100,000 population)
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American Indians/Alaska Natives
Asians/Pacific Islanders
2004 2005
such as poverty and lack of access to health care, in contrast to inherent factors,
account for this discrepancy.
Factors Contributing to the Spread of STIs
According to the Institute of Medicine, “STDs are behavioral-linked diseases
that result from unprotected sex,” and behavioral, social, and biological factors
contribute to their spread (Eng & Butler, 1997). These factors are obstacles to
the control of STIs in the United States.
Behavioral Factors
Early Initiation of Intimate Sexual Activity People who are sexually active
at an early age are at greater risk for STIs because this early initiation increases
the total time they are sexually active and because they are more likely to have
nonvoluntary intercourse, to have a greater number of sexual partners, and to
use condoms less consistently (Manlove, Ryan, & Franzetta, 2003). For example, a nationally representative sample of 9,844 respondents found that the
odds of contracting an STI for an 18-year-old who first had intercourse at age
13 were more than twice those of an 18-year-old who first had intercourse at
age 17 (Kaestle, Halpern, Miller, & Ford, 2005).
The more exclusive sexual partners an
individual has over a period of time (called serial monogamy), the greater the
chance of acquiring an STI. (For a discussion of serial monogamy, see Chapter 7.)
For example, according to one national study, 1% of respondents with
1 sexual partner within the past year, 4.5% of those with 2–4 partners, and
5.9% of those with 5 or more partners reported that they had become infected
with an STI (Laumann, Gagnon, Michael, & Michaels, 1994). In addition,
the more sexual partners respondents had, the more likely it was that each of
those partners was unfamiliar and nonexclusive. Being unfamiliar with partners, especially knowing the person for less than 1 month before first having
sex, and having nonexclusive partners were both strongly associated with
higher STI incidence. Data from the National Survey of Men and the National
Survey of Women discovered that the likelihood of contracting an STI
increased with an increase in the number of lifetime sexual partners: Compared
to persons with 1 partner, those reporting 2 or 3 partners have 5 times the
likelihood of having an STI, and the odds were as high as 31 to 1 for those
Sequential Sexual Relationships

Chapter 15
Sexually Transmitted Infections
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reporting 16 or more lifetime partners (Tanfer, Cubbins, & Billy, 1995). A study
found that 34% of sexually active women aged 15–44 were at risk for STIs
because either they had more than 1 sexual partner (21%) or their partners had
2 or more partners (23%). Interestingly, 20% of the women whose partners had
multiple sexual partners thought that they were in mutually exclusive sexual
relationships. Among men aged 18–24, 24% were at risk for STIs because of
having 2 or more sexual partners (Finer, Darroch, & Singh, 1999).
Concurrent Sexual Relationships Having concurrent sexual relationships—
overlapping sexual partnerships—facilitates the spread of STIs. Research has shown
that sexual concurrency is associated with individual STI risk (Manhart, Aral,
Holmes, & Foxman, 2002). This risk is especially true during acute HIV infection,
when transmission is greatest. A nationally representative study of men found that
11% reported concurrent sexual relationships in the past year, mostly involving
women. These men were less likely to use a condom during their last sexual
encounter; were less likely (than those not reporting concurrent sexual partners)
to be married; and were more likely to report several risk factors including drug
or alcohol intoxication during sexual intercourse, nonmonogamous female and
male partners, and sexual intercourse with men (Adimora & Schoenbach, 2007;
Doherty, Schoenbach, & Adimora, 2009). Among women in a nationally representative study, the prevalence of reported concurrent sexual relationships was
12%, with lowest concurrency being among those currently married (Adimora
et al., 2002). A study of STI clinic patients—one half reporting concurrent sexual
partners in the past 3 months—found that both men and women believed that
having concurrent partners was normal. They thought that no one was exclusive
and that, based on previous relationships with nonexclusive partners, they found
it difficult to trust their partners and be emotionally invested in the relationship.
Most of the study participants, particularly the women, were looking for exclusive
sexual relationships (Senn, Scott-Sheldon, Seward, Wright, & Carey, 2011).
Having sex with a person who has had many
partners increases the risk of acquiring an STI. One example of this is a female
who has a bisexual male partner. Often, the female does not know that her
male partner also has sex with men. Another example is when an older, sexually
experienced person has sex with a younger and less experienced partner (Boyer
et al., 2000; Thurman, Holden, Shain, & Perdue, 2009). Also, a survey of
1,515 men aged 18–35 attending health centers found that those who had
purchased sex were twice as likely to be infected with an STI than those who
had not purchased sex (Decker, Raj, Gupta, & Silverman, 2008). People often
select new sexual partners from their social network. If a person acquires an
STI, then the social network could be considered a high-prevalence group, thus
increasing a person’s chance of future STI infections. Research has shown that
selecting new partners f …
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