Ep. 122: The Birds, The Bees, & All These STDs

[00:02] Episode Preview: STIs Don't Have an Age Limit

Ep. 122: The Birds, The Bees, & All These STDs

Host: Dr. Kanwal Bawa | Guest: Dr. Patrick Kenney | Runtime: 25:21 | Published: April 9, 2024

Dr. Bawa: With the advent of erectile dysfunction and vaginal rejuvenation treatments and even hormone therapy, people are having sex older and older in life. And so they think that just because they can't get pregnant, they don't need any kind of protection.

Dr. Kenney: Absolutely. I can't tell you how many patients I see that are over the age of 55 that are coming to me with signs or symptoms of sexually transmitted infections. And they are blown away when I tell them, “Oh, you have gonorrhea.”

[00:34] Welcome: What You Really Need to Know About STIs

Dr. Bawa: And they're like, “Whoa.” Welcome to America's number one sexuality podcast, Dr. Sex Fairy. I am Dr. Kanwal Bawa, America's favorite sex doctor, and I am here to transform your life. The Dr. Sex Fairy Podcast is both audio and video, so don't forget to subscribe to our YouTube channel, Dr. Sex Fairy, as well as subscribing on Apple Podcasts, Spotify, or wherever you get your podcasts.

Dr. Bawa: Today we are delving into a topic of utmost importance, and that topic is what you really need to know about sexually transmitted infections, or STIs. Joining me today is a distinguished guest, a respected South Florida-based fellowship-trained infectious disease specialist. He practices at none other than the world-renowned Cleveland Clinic, which also happens to be where I trained.

Dr. Bawa: But here's a delightful twist to our story. Dr. Patrick Kenney and I were once fellow students navigating the craziness of medical school together. We sat side by side, burning the midnight oil, preparing for exams, and dreaming of making a positive impact on the world of healthcare. Life, as it often does, took us on divergent paths during our residencies and the early years of medical practice.

Dr. Bawa: Yet, over two decades since our first meeting, it is an absolute pleasure to welcome my dear friend to the Dr. Sex Fairy Podcast. Today, Dr. Kenney and I are here to unravel the fact and fiction surrounding sexually transmitted infections. We will discuss prevention, testing, and the latest advancements in STI management.

Dr. Bawa: So whether you are seeking vital information for your own sexual health or looking to better understand and support someone else's, you are in the right place. Join us on this journey to demystify STIs, promote awareness, and equip you with the knowledge you need to lead a healthy and informed life. Without further ado, let's get started with this wonderful conversation. Welcome back to the Dr. Sex Fairy Podcast, my friend.

Dr. Kenney: It is so awesome to be here. Thank you so much for having me again.

Dr. Bawa: I am tickled silly that we are doing this because I adore you. So that's step one. It makes the conversation more fun.

Dr. Kenney: Absolutely. And I adore you as well.

Dr. Bawa: Well, thank you. And it's such an important conversation.

Dr. Kenney: It truly is. And it's a conversation that we should all be having.

[03:14] STD vs. STI

Dr. Bawa: Absolutely. Now let's start with STD versus STI. I still mess that up myself.

Dr. Kenney: You are not alone. I myself do it all the time. So we were trained STD, STD, sexually transmitted diseases. And then when you stop and think about it, it's not really a disease, it's an infection. And infections have treatments, and the vast majority of those infections can be cured, if not treated.

[03:41] The Most Common STIs

Dr. Bawa: What are the most common STIs?

Dr. Kenney: Well, the most common STIs, it really depends on the region and where you are. Down here in South Florida, I would say syphilis is very, very common. Gonorrhea and chlamydia are a close second and third. And it really just depends on the population.

Dr. Kenney: So if I were to say within my scope of practice, I have a very large LGBTQ population. So I see a great number of patients with gonorrhea and chlamydia on screenings. But syphilis is also very, very high. Like I said before, it's one of the ones that I always encourage my medical students and residents to think about when they're doing H&Ps, when they're doing sexually transmitted infection screenings of patients.

Dr. Bawa: Syphilis is back in a big way.

Dr. Kenney: Very much so. Down here in South Florida, it's exploding. But this is a very old infection. This has been traced back to the times of the Middle Ages. And we have depictions of patients with syphilis. Very notable people in history have had syphilis cases. So this is something that has not gone away, but this is something that people think of as an old infection. It's like tuberculosis: “Oh, people don't get that.” Of course they do. The human body hasn't changed.

[05:06] STIs in Older Adults

Dr. Bawa: And what I find interesting is that with the advent of erectile dysfunction and vaginal rejuvenation treatments and even hormone therapy, people are having sex older and older in life. And so they think that just because they can't get pregnant, they don't need any kind of protection.

Dr. Kenney: Absolutely. I can't tell you how many patients I see that are over the age of 55 that are coming to me with signs or symptoms of sexually transmitted infections. And they are blown away when I tell them, “Oh, you have gonorrhea.” And they're like, “Whoa.”

Dr. Kenney: Patients are so surprised when they find out that they have a sexually transmitted infection, and they go through this rationale in their head that, “Well, I was only with that one person, and he looked fine,” or, “She looked fine. Everything was fine.” Well, if you're having sex, the risk of sexually transmitted infection is always there. And this can come with lack of education and awareness that we need to provide our patients.

[06:15] HIV Screening and Taking a Sexual History

Dr. Bawa: Is HIV still as big a concern as it once was?

Dr. Kenney: Absolutely. There is much more awareness of HIV now than there ever has been, thanks to over 40 years of being in this epidemic and pandemic. And so one thing that I always like to make sure that people understand is that if you are sexually active, you really should get HIV screened regularly.

Dr. Kenney: So if you are sexually active with more than one or two partners, HIV screening is absolutely necessary. The United States Preventive Services Task Force recommends that all individuals over the age of 15 should be screened for HIV at least once. And if you are sexually active, especially in our 15- to 30-year-old patients, upwards of twice to maybe four times a year, depending on the level of activity.

Dr. Kenney: And so it's very important that we get a good sexual history on our patients, coming at it from a very nonjudgmental way. “Are you sexually active?” It's a very simple question, yes or no. “If you are sexually active, are you sexually active with men, women, or both?” And then I find in my experience that patients tend to drop that guard, and they're able to be more open with you and tell you what kind of sex they're having, and then you can best educate and screen your patient.

[07:45] HIV, Relationships, and U=U

Dr. Bawa: That's great to know. And I understand that HIV is such a complex issue that we have to have you back to just discuss HIV by itself. But tell me about how people who are with partners who are HIV positive are able to still have fulfilling sex lives.

Dr. Kenney: This is very much a change from when we were training. So when we were training, a lot of my HIV-positive patients that I would see early on in my career would do something called serosorting their potential partners: “Okay, I'm HIV positive. I'm only going to date HIV-positive partners. I'm not even going to look at HIV-negative partners because I don't want to transmit this virus to anybody else.”

Dr. Kenney: And conversely, HIV-negative people would discriminate against HIV-positive partners out of fear of potential exposure. Now, through many studies, which we could go into a whole other episode about, there have been a multitude of studies that show that an HIV-positive partner who is on medication, who is undetectable, meaning that the levels of virus are undetectable in blood, can have an HIV-negative partner and not transmit that HIV virus to that negative partner.

Dr. Kenney: Over 10,000 couples with zero discordance, meaning a positive partner and a negative partner. And those numbers, as we know from school, are very statistically significant. So it has gone so far that the World Health Organization has actually come up with the campaign U=U, meaning undetectable equals untransmittable.

Dr. Kenney: So with that, this has changed the dating realm and the sexual practices of both HIV-positive individuals and HIV-negative individuals, because now that fear of transmission is gone. However, I always say there's always that little asterisk that you have to be open and honest with every partner that you come across in life.

Dr. Kenney: If you are HIV positive, you need to tell your partner, obviously, or potential partner, right away, and go a bit further and say, “I'm on medication. I am undetectable.” And you can show those lab results to a potential partner because that right there shows respect for that potential partner and trust-building, especially early on in a relationship when one is becoming sexually involved.

[10:37] Disclosure, Trust, and HIV Stigma

Dr. Bawa: Yes, I think if you are honest with them to begin with, right up front, that's a whole other ballgame than if you trick them into having sex with you.

Dr. Kenney: Absolutely. Relationships are built on trust and honesty. So being honest and a bit vulnerable, as many of us are in the beginning of a relationship—you know, it's always like one of the best parts of a relationship—when you are honest, you will definitely reap the benefits.

Dr. Kenney: And that partner to whom you're being honest is going to respect you and feel respected because it's something that you really need to disclose. And disclosure is key.

Dr. Kenney: And like I tell all my HIV-positive patients, because a lot of HIV-positive people, when they come to see me, especially new in the infection, they feel, “Oh my gosh, my sex life is over. No one's going to want me.” And that's so not true. And I say, “The only people that need to know your status are you, me, the doctor, and the people you sleep with.” That's the only one who needs to know your status.

Dr. Kenney: So really, the playing field has changed, the rules have changed, and that's the beauty of medicine. We have to stay up to date on these things. Otherwise, we're stuck in the past, and this virus comes with so much stigma that the more you demystify things, you drop that stigma, and we can just be people and we can be providers helping these people live their normal life.

Dr. Kenney: Because now our HIV-positive patients that are on treatment, HIV is the least of their problems. Their risk of dying from HIV is less than driving on I-95, which, anyone who's driven in South Florida knows, is a high risk. When you know, you know.

[12:38] HIV Then and Now

Dr. Bawa: Now, when it comes to HIV, I think we are seeing that our patients are living long, healthy lives. But a lot of the stigma is coming from the images we have seared into our minds of people like Freddie Mercury who just withered away.

Dr. Kenney: Absolutely. And I think for us who were raised in that, I call it the in-between years. Someone like my parents' age, they lived through the sexual revolution. And out of the sexual revolution, unfortunately, HIV was one of the things that fell out of that revolution where people were being free and loving one another and sex, and people weren't as constrained to the norm. People had multiple sexual partners and they were open about having multiple sexual partners.

Dr. Kenney: And then from HIV, when that whole pandemic started in the beginning of the '80s, when we were just little kids, we saw our parents' friends and relatives wither away, and movie stars and musicians and multiple people just wither away and die. And those images never leave us.

Dr. Kenney: So for us that were raised during that time, during our formative years, and then going to medical training, we saw patients that were like that. And now, unfortunately, we're still seeing young people becoming infected, but they're living normal, healthy lives.

Dr. Kenney: Right now, anyone on HIV treatment can live their best life and be completely disease-free as long as they take the medication and they follow up with their treatment and get routine checkups. Now my HIV patients are screened maximum twice a year to make sure that their immune system is doing well and that the virus is still undetectable. The other things that they have to worry about are heart disease and diabetes and all the other things that we have to worry about.

Dr. Kenney: So it takes a long time to change those attitudes. But with platforms like this and having open-minded providers that are willing and able to talk to patients at a human level, I think we can make a huge difference.

[15:10] Herpes: Common, Misunderstood, and Manageable

Dr. Bawa: I think we can. Let's now shift the conversation to herpes. Very common.

Dr. Kenney: Very common. Very, very common. So as many people know, and many people don't know, herpes simplex virus—there are several types, but the most common being herpes simplex virus 1 and herpes simplex virus 2, HSV-1 and HSV-2. These viruses are very, very common. They're very transmissible through even casual contact.

Dr. Kenney: So when I get a patient that comes to see me, they always ask me, “I want the full enchilada of STI screenings.” And I say, “Absolutely, not a problem. But let's talk about herpes.” Because they say, “Well, yes, of course, I want to be screened for herpes.” No problem. But let me tell you what's going to happen.

Dr. Kenney: I'm going to screen you with a test called a serology, a blood antibody test. It is going to test if your body has ever seen that virus before. Now, that test may, for the most part, be positive. And people get really freaked out and it causes a lot of drama. So with experience and age, we learn to mitigate that drama by just saying, “This test is most likely going to be positive.”

Dr. Kenney: This test will not tell me when you acquired HSV infection. It will not tell me how long you've had it. It will not tell me if you'll ever have an outbreak.

Dr. Kenney: So I always tell patients, if you ever have an HSV lesion—and those are blister-like lesions—wherever that virus was acquired, whether it's on the lips or in the genital area or the anal area, we can actually open up one of those lesions and do PCR testing on those lesions to see what virus we're dealing with.

Dr. Kenney: And then we can talk about ways to prevent transmission to a partner. Because if a patient comes to you and says, “Oh, I want to know about herpes,” we have to start asking questions. “Have you ever had cold sores or ever had any blisters in your genital area, especially around times of high stress?” In women, especially around the time of their menstrual cycle, we can see outbreaks of HSV.

Dr. Kenney: And really, then we can better educate the patients about HSV transmission and prevention, because there are ways to treat HSV infection with antivirals that can be taken during an infection and even indefinite antiviral suppression. But we really need to talk about that. That's the discussion that needs to be had with your provider.

[18:01] HSV-1 and HSV-2 Can Live in Different Places

Dr. Bawa: The other thing I've noticed about HSV and the misconceptions about it is that people think HSV-1 is oral and HSV-2 is genital. And both can live in both places and other places.

Dr. Kenney: Of course. And yes, that is a very big misconception. Like we discussed in an earlier episode with HPV, HSV does not discriminate where it is deposited.

[18:30] Oral Sex Can Transmit STIs Too

Dr. Bawa: I think another important issue that we should discuss is that people think that they only get STIs from actual penetrative sex, whereas oral sex can cause just as many, if not more, STIs.

Dr. Kenney: That is correct. So most commonly people say, “Oh, you know, I had protected sex.” But I'm like, “Okay, but did you use protection during oral sex?” And they're like, “No.” And that's a good conversation to have because I have found many gonorrhea and chlamydia infections in the throat, in the anal area, and vaginally, of course.

Dr. Kenney: But since we're talking about oral sex, I always ask patients: listen, if you are practicing oral sex, there's no barrier between mucous membranes or surfaces of your body. So especially early on in a relationship, you can certainly protect yourself by performing oral sex with the use of condoms or dental dams to prevent transmission of certain infections, especially gonorrhea and chlamydia.

Dr. Kenney: HIV is a very low risk of transmission during oral sex. It's very negligible. They have not been able to pinpoint an HIV infection from oral sex alone. Is it completely impossible pathophysiologically? No, it's not impossible, but it's highly unlikely.

Dr. Kenney: However, gonorrhea, chlamydia, syphilis, and herpes are certainly transmissible. So it's very important that we educate our patients that, yes, you can use barrier methods to protect yourself during oral sex. Now, once you're with a certain partner for a particular period of time and you've gone through STI screenings and you feel you want to take those barrier methods away, go for it. Have fun.

[20:42] HPV Vaccination and Doxy-PEP

Dr. Bawa: So, Dr. Kenney, as far as vaccination is concerned, for the most part, HPV is all I can think of.

Dr. Kenney: Well, as far as vaccination is concerned, you are correct. And as our listeners may have heard in a previous episode, the HPV vaccine is available. It's available for children as young as nine and adolescents up to the age of 26. However, we have also found that HPV vaccination can be given in older adults up to the mid-40s.

Dr. Kenney: So it's very, very important to have the conversation with your provider if you have not been vaccinated for HPV and you have not been found to have an HPV infection, to protect yourself with a very easily given vaccination. It's a three-shot series. The first one is given, then one a month later, then the third one six months later.

Dr. Kenney: But another interesting fact is that there has been a transition to a new form of prevention for STIs called doxy-PEP. And doxycycline has been around forever. However, there have been wonderful studies that have been done that show that two pills within 72 hours after having unprotected sex have been shown to prevent transmission of gonorrhea, chlamydia, and syphilis.

Dr. Kenney: And these are late-breaking studies. The FDA has not yet fully approved doxy-PEP, but it's definitely in the final stages of approval based on the studies done by Kaiser Permanente and other major groups that have been trying to limit STI transmission in the population.

Dr. Bawa: So it's the new morning-after pill.

Dr. Kenney: Exactly. Exactly. And, of course, we have to educate our patients that it's not foolproof. We have to make sure that you're getting your screenings regularly. And if there is a positive screening, make sure that you inform your partner so that they can be treated as well to prevent transmission.

Dr. Kenney: I think ultimately the main takeaway point from all of this is just to be open with your patient, and for patients to be open with their doctor. Because the more we are able to learn about our patients, we can help them. And we are ultimately getting into a part of their life that's very intimate, but we need to be part of that. We need to be part of their life in that way so that we can best help them live their best life.

Dr. Kenney: Because sex is a wonderful thing. We should all be having sex, but healthy sex. And we should be healthy in all aspects of our life, and sexual health is no exception.

[23:45] Closing Conversation

Dr. Bawa: And wow, I couldn't have ended this podcast episode any better than you just did.

Dr. Kenney: Oh, thank you.

Dr. Bawa: Thank you so much for your pearls of wisdom. Thank you for coming back on the podcast, and we have to bring you back for so much more.

Dr. Kenney: I will be honored. Thank you so much.

[24:01] Recorded Outro

Dr. Bawa: As we conclude this episode, I want to remind you that knowledge is power when it comes to sexual health. By staying informed and having open conversations about STIs, we can create a healthier and safer environment for ourselves and our communities. Don't forget to share this episode to spread the word.

Dr. Bawa: I want to express my gratitude to our guest, Dr. Patrick Kenney, for sharing his expertise and insights. It's been a heartwarming reunion, revisiting our medical school days, and discussing this vital subject that affects so many lives.

Dr. Bawa: Thank you for spending time with me on this episode of the Dr. Sex Fairy Podcast. If you are watching this on YouTube, don't forget to leave questions and comments. I will answer them personally. Make sure you like this video and subscribe to my channel, Dr. Sex Fairy, so that you never miss an episode.

Dr. Bawa: If you are listening on Apple Podcasts, Spotify, or elsewhere, do subscribe to the Dr. Sex Fairy Podcast. We have lots more great content and guests to come. Check out my super-hit TikTok account, Dr. Sex Fairy, and my Instagram, The Real Dr. Sex Fairy. Until next time!