Transmitted Infections , Sexuality and STI Stigma among Nepalese youth and adults

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Introduction
Globally Sexually Transmitted infections are among the most common public health problems with their prevalence ranging widely (From less than 1 % to up to 40 % among the reproductive age group population of different communities.It is estimated that every year more than 340 million new cases of curable STIs occur globallyl,2 and it is also estimated that 1 in 4 Americans have STIs3 at any point of time. STIs in Nepal have also been considered as a major group of diseases causing significant morbidity amo.ng some targeted group of population including the youths.It is been dealt along with HIV by a separate wing of the Department of health from the ministry of health and population of Government of Nepal, called NeASC (National center for AIDS and STD control) in close coordination with many other national and international non governmental organizations.The true prevalence ofSTI in Nepal is not known but small scale studies carried out in different groups of population have reported STIs to be one of the major public health problem 4 of the country.
The sufferings from S TIs are reported from the ancient time with different descriptions, which shows that the illnesses are as old as the humankind.However, STIs had not been able to grasp the significant importance among public health, till its relationship with HIV infection has been strongly established. 5'6'7 Today,STIs stand together with HIV infection as the major public health issue and billions of dollars are being spent globally to find the ways on how to provide efficient treatment and how to avoid STIs.The success of such efficient STI management program in the long run, is expected to significantly reduce HIV transmission as evidenced by the reports of Rakai, Masaka and Mwanza study from 199~-1998.7Most of the STI management programs gi!ve major focus to diagnose treat and prevent STIs, but almost negligible attention is given to cover up the psychological aspects of the disease~ Stigma, which is defined as 'the negative judgment and prejudice towards those who are infected and affected' , is very high among STI population.STIs being considered as a social taboo in the society, persons infected to it are not socio-cult:urally accepted.Still a high degree of discriminations (defined as 'unequal treatment to those who are known as infected or affected') prevail to those who have any S TIs, even by the health care providers.The fear of discrimination further increases the tendency to hide the disease and thus promotes the disease progression and thereby causing unlimited burden of self-stigmatization on STIs.
As a consequence of a high level of stigma and fear of discrimination on STIs within the society, in one hand it leads to the tendency to hide the infection at the individual level, which further helps to increase the morbidity caused by the disease progression and their sequele as well as promoting its transmission to others.And in other hand, it further causes significant anxiety or depression to the affected individual even when the individual is completely cured of the infection or there is no such infection 'at all, ultimately increasing the sufferings of the individual and his/her family to a greater extent.

Results
Out of 1852 male adolescents, youths and adults with genital complaints only 28% had true STls and the rest 72% were either already cured or had no STls at all, but were having strong self stigma of STls.The majority of the study population belonged to youth and young adults and slightly more than half were married (Table 1).Out of the total study population, only 27.6% of them were found to have one or more STls during the time of the study and the rest (72.4%) although strongly believed that they have one form or other of STls, were not having any STls in reference to the clinical and available laboratory tests (Table 2, Fig. 1).The major presenting symptoms of the study population were found to be as follows (Table 3).Burning or prickling pain, itching, sore or superficial erosion, discharge, premature ejaculation and decreased sexual desire or erectile dysfunctions etc. were among the commonest.Although, 49.2% of those having extramarital sex were found to have used condoms, only 7.8 % were using it consistently with all of their sexual partners.55 out of782 (7%) of those using condom replie~ that the condom was broken in one or more occaSIons. ,among the normal couple on their sexual function had revealed that 40 % of men and 63 % of women had some form of sexual impairment.Similarly, several studies have proved that, illitenicy with lack of sex education leads to the' sexual dissatisfaction because many of them• can not differentiate between what is normal and what is abnormal sex behavior.Since even those persons who confess that, they had never had any sexual contact with other partners, think that they are suffering from some S TIs which have resulted in different manifestations. 8In this context, the present study clearly indicates the role of adequate sex education among the youths and the need of proper STI Counseling and psychotherapy to the sufferers.

Conclusion
The study, one of the first of this kind in Nepal, revealed that a significant number (>72%) of male youths and adults suffering from some form of genital symptoms were on self stigma of having STIs, although they had none.Although almost 86% were having extramarital sexual relationships, only about 49% were found to be using condoms at some point of time and more over, only 8% were found to have used it consistently.More than 95% of them were having heterosexual contact.63.5% were found to have only vaginal intercourse; however the rest 36.5% were also having oral and anal sex.The study also reveals that, the lack of knowledge regarding sexual drive, sexuality and reproductive health among the youths and adults make this group vulnerable to different mode of sexual activities.Because of their indulgence in those activities, which normally is not accepted by their society and their culture, leads them to selfstigmatize on STIs and manifest with bizarre symptoms.Moreover, these groups of youths are mostly found to have anxiety or depression due to deeply rooted stigma onSTIs and so are need of proper education and awareness on STI and sexuality along with counseling on STI management and psychotherapeutic support.

1 .
To identify the prevalence of self stigma among youths and adults. .2. To find out the true prevalence of STls among those youths and adults having STI related symptoms.3. To study the pattern of sexual behavior and sexuality among them.4. To find out the common mode of sexual act among themJuly 2002-June Study: "Sexuality, SexualLy Transmitted Infections and STI Stigma among Nepalese Youths and adults" Place: Department of Dermato-Venereology of TUTH and private clinic Method of information collection: Defined Format of proforma on: Demographic data, sexual history, ~ymptoms, clinical fmdings, laboratory fmdings and.diagnosis along with the individual's self evaluation status on STls

Fig. l .
Fig.l.Percentage distribution of various STls.

Fig. 3 .
Fig.3.Sexual contact history of patients.Note: Out of the total 1591 who gave history of

Table 1 .
Age wise distribution and Marital status of the study POlJUlation

Table 4 .
Mode of sexual act: