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WOMET¥ A\D HEALTH
■'X®
C.H.A.I. V.II.A.I. Dialogue.
Hyderabad, March 13-14,1993.
■<g
.
E-
-S
Hui' "
cj'1^
.
GYNAECOLOGICAL
DISORDERS
I-
■'
■
.
Voluntary Health Association of India
*1
women&gynaecological disorders
1
The existence of gynaecological problems of
systematically under estimated and mismanaged.
women
has
been
Crimes'' of “ negligence are usually committed quietly specially
when it is patriachal society which has constantly undermined
the? status of .women. .The reasons' have been several main of
course 'is:, \ *
W
.
^discrimination ’against women resulting *in
‘their contributions, and their problems;
I
negation -of
women,
e.clipsing of all other womens health problems by aggressive
Population Control activities in the name of MCH;
-negation of self and their own problems by women themselves
due to priority given to_ the needs, of their husband ‘and
children even when suffering with acute pain and severe
'discomfort for prolonged periods;
*the presence of double standards in our society results
to' in many innocent housewives being made vulnerable to
STD and AIDS from their own husbands.
husbands. These men in many
situations are victims themselves of distorted development
patterns which force men to seek employment in heartless
^cities far removed from hearth and home. Since sexual matters
and matters related to 'private poits', are private matters,
women continue to suffer in silecne, the pain, the discomfort,
and discharge and disparunia (pain during intercourse).;
♦ignorance about the causation of gynaecological problems,
infact . ignorance of the basic anatom;
and physiology of
t the body made worse by prevailing myths] makes matters worse
eg. that intercourse with a young virgin girl is a treatment
of veneral disease.;
I
♦unlike male problems, due to the nature of female anatomy
-gynaecological; infections and problems become obvious ..only
after they have long passed the early stages.;
♦difficulty in< examination partly due to the
womens \own
and ‘ lack of
adequate
hesitation
equipment
eg-, speculum,
'examination table's, travelling and <adequate privacy required
ffor any tsuch ^examination
r
further delays the diagnosis which
is crucial for?proper treatment;
r1
functioning,
^inadequate training,
timings
and
gender
of
f the health. personnel
at
health
institutions,
inadequate
diagnostic and therapeutic facilities
to
deal
with
the
diseases
from
the
gynaecological
very
common
menstrual
leucorrhea,
genito
problems,
urinary
infection
to
STD,
AIDS, etc.
:2:
There is a need of sensitivity and openness about dealing
women's
'with
gynaecological1: disorders
because
women's
hesitation
medical
<
embaressment to seek
care
often
results
in
the
infections becomes too far spread and too serious.
' With f the ' incidence of STD going up, with women with ulcers
"or cervical lesions become more predisposed to pick up BI V
infection,
with
non
availability
adequate
of
diagnosti s
.facilities for common leucorrheas or for ’Papsmear’ for cancer
of ' cervix,
thq commonest cancer among Indian women,
lack
of adequate medicines to treat even if the diagnosis is made,
makes the. situation worse.
.Lack of privacy even for bathing,
toilet facilities,
lack
of adequate water, lack of adequate menstrual care due to
5 myths, ignorance or result in the problem of gynaecological
’diseases being found in a much higher incidence. In a community
based study 92% women had been found to be affected, according
to Dr.Rani Bang’s Community based Epidemiological study in
Gadcharoli District in Maharashtra, The study had found that
average incidence of gynaecological problems at
the
time
►I
of the study was 3.2 per person.
to
Dealing
with
gynaecological
problems
is
not
merely
effectively treat pain.and suffering bitt work towards preventing
it, by ensuring availability of the health facilities, of
trained health personnel, but using it as a tool to demystify
0 and demolish, existing,myths and challenge some of the negative
practices,
and work towards women learning to accept and
respect themselves and their womenhood inspite of what Manu
represent, Women
°Smiriti alleges and what ’Eve’ i^s alleged to represent.
chave been • blessed with the gift of creation, this should
“not become a woe because of repeatedly inflicted unwanted
^pregnancies,
where attempts
at
terminating
the
pregnancy
creates health hazards for the women, or the mere exercise
of,’child birth’ ends.with injury and gynaecological infection,
'^needless,
needless, surgery and consumption of irrational and hazardous
"drugs,
drugs, contraception and consequences of conception becomes
• hdr. responsibility alone and she must pay the price.
Efforts is helpingHn understanding of their own female anatomy,
health . problems, ------------- 4-1
-___>
----their' common
ways of preventing
them
and
managing .them has *I to be ensured, through popular education.
Creatidh of ’Shari'r Ki Jaankari ’ by the Sathins of Ajmer
and health workers like Dr.Sathyamala, published
by
KALI
,^.s a very good example since theproblems affect the healthof
’so many women those involved in issues of women whether i-t
be education, organisation or the highly funded AIDS programmes, •;4
,the question of preventing and treating gyanecological disorders
’specially STD etc. has to be put on the agenda.
:3:
Awareness about
gynaecological
disorders
will
undoubtedly
^result in questioning the * roots of many of these problems
eg.frwith STD & AIDS’ it.' will result in confronting the issues
.related to responsible sexual behaviour and meaningful relation
ships and not Just practice of
’safe sex’ where in place
•of caring, sharing, concern and genuine regards and respect
for the 'partner’ is an exercise in irresponsible, self gratifi. cation where women are treated as mere tools or sex objects.
Dealing with gynaecological disorders like STD &
serious questioning of the patriarchal diseases,
AIDS
requires
i«
Issues that arise are many, is it violation of wifely duty
when ai women exhausted or unwell says
'no'
to her husband
and denies him his sexual plea'sure. If it is she who must
take full responsibility for the use of the consequence of
the usage of contraceptive technologies eg.
insertion
of
fVCD, when her gynaecological infection is not first or at
least simultaneously treated,
or long acting hormonal pre
paration when she is highly anemic and has bleeding ’ problems.
When she must bear the consequence of conception or abortion
doq^ she have any say over her own body? Is she in a position
to say no and' not be made to feel guilty for i t or punished
for it.
In a society where male double standards are very well known
. where the price paid for is always by the woman,
there is
* a 4 need to question, these double standards and work towards
responsible and caring, attitude and behavious towards women
and relationships with them.
In this era of ’disposables' women cannot be allowed to be
1 consumable’
treated
as
'consumable'
'disposable'
sexual
commodities,
and unless these issues are dealt- with seriously treating
STD & AIDS like
'water borne',
'vector borne disease' or
diseases caused by 'dioplet infections is being unrealistic.
The health personnel concerned about the issues of women's
• health specially STD, AIDS must strengthen the hands of the
women, by helping them help themselves, to gain self awareness,
self confidence, skills and knowledge so as to be able to
prevent gunaecological disorders as far as possible or seek
medical help when needed and refuse any exploitation in the
name 'of medicine eg. repeated Dilatation and Curettage, ultra
bounds, pumping of hormones, when they are not needed. The
pain and suffering of chronic Pelvic
Inflammatory Disease
only the victim knows. The pain of infertility is differentit is not physical but psychological and social - where a
woman unable to bear a child is faced with harassment and
humiliation sense of rejection and negation.
in
Probably
:4;
no other problem do women suffer so much from their loved
ones from society and themselves as they feel like failures,
Women go from pillar to post repeating needless investigations
many times over often recommending doubtful treatments with
Over ■ confidence.
Dealing with causes of infertility and humane and management
Of Infertility is very much needed with simple guidelines
and’ simple list of referal centres and centres where babies
are awaiting adoption.
be
a
iSeeking freedom from gynaecological disorders would
assertion ’ and
empowerment
1 major’5 step in responsible self assertion
of women which will not merely in greater contribution of
women in being able to lead healthier lives but to their
families and society to which they contribute significantly
anyway,
i
,
• ’
Dr.Mira Shiva MD
Head^Public Policy Dvn.VHAI
i
lANG*^
medico friend
159 circle
bulletin
January 1990
HIGH PREVALENCE OF GYNAECOLOGICAL DISEASES IN RURAL INDIAN WOMEN
R. A. Bang
A. T, Bang
M. Baitule
Summary
A population-based cross-sectional study
of gynaecological
and
sexual
diseases in
rural womerf was done in two Indian villages. Of
650 women who were studied, 55% had gynaecolo
gical complaints and 45% were symptom-free. 92%
of all women were found to have one or more gyn
aecological or sexual diseases, and the avarage
number of these diseases per woman was 3’6.
Infections of the genital tract contributed half of
morbidity, Only 1 % of the women had undergone
gynaecological examination and treatment in the
past. There was an association between presence
of gynaecological diseases and use of female meth
ods of contraception, but this could explain only a
small fraction of the morbidity. In the rural areas of
developing countries, gynaecological and sexual^care should be part of primary health care.
Introduction
MATERNAL and child health care is one of
the eight basic components of primary health care
in the Declaration of Alma-Ata. In some progra
mmes, a more focused approach has been advoca
ted and promoted—termed selective primary health
care or child survival revolution. There is now
concern about the. health care of women during
!•
Y. Choudhary
S. Sarmukaddam
O. Tale
pregnancy and childbirth, and prevention of maternal
mortality has been indentified as a priority. By
contrast, little attention has been given to the repr
oductive health of non-pregnant women.. In third
world countries, such women tend to encounter the
health care system only when they are the target of
family planning programmes.
The term gynaecologica I diseases is used
in this paper to denote structural or functional dis
orders of the female genital tract other than abnor
mal pregnancy, delivery’ or
puerperium. One
reason for the relative neglect’ of gynaecological
care is a failure to appreciate the extent of unmet
needs in rural
areas.
Most of the
data are
from hospitals or clinics and are highly selective;
they give no idea of the rates in the population.
The few population-based studies have focused
only on specific disorders—ie, cervical cancer (cho
sen for study because of hospital experience ),
vaginal discharges, and genital infections ( based
on family planning clinic data ). We are unaware
of any population-based study of the whole range
of gynaecological diseases in developing countries.
An additional reason for lack of information on
these disorders is the extreme scarcity of female
doctors in the rural areas of developing countries.
Tra itionally
women from these areas are very
relubtant to talk to or be examined by male doctors
‘ for gynaecological or sexual disorders. Nurses and
paramedical workers are not trained to deal with
gynaecological diseases; so the result is near tota1
absence of care.
In the present study we sought to determine
(1) the prevalence, type, and distribution of gyna
ecological diseases in rural women; (2) awareness
and perceptions of the women about their gynaecological and sexual disorders; and (3) the propor
tion of women who has access to gynaecolog cal
care.
<•
SUBEJCTS AND METHODS
Study Area and Sample Population
Gynaecological inquiry and examination is a
very sensitive matter for rural women in India. One
cannot randomly select a few women from a large
popu ation and descend upon them. Hence it was
decided to make villages the units of study.
The instigation was conducted in Gadchirolj
district, a backword district of Maharashtra state.
Two villages were selected on the following criteria : s □cioeconomic composition similar to that of
the average village; leaders who could understand
the nature of study and would persuade the women
to participate; pravalence of gynaecological disea
ses not known to be atypical.
Village A had a population of 1406 and
village B 22q0.
They were located 20 km from the
district town and from each other. Both had perennial roads. A primary health centre with two male
doctors was located in village B while a small mis
sion hospital, run by the nurses was located in
village A. Thus both the villages had good access
to primary health care, thongh the nearest gynaeco
logist was at the district town.
Female social workers, village leaders, and
volunters invited all females who were aged 13 years
and above or had reached menarche to participate
in the study, whether or not they had symptoms.
Investigations
A field camp was set up in the village, first
in A then B, with facilities for interwiew in privacy
and pe|vic examination, pathology laboratory, and
operating theatre. A base pathology and bacterio
logy laboratory was established at the project
headquarters 20 km away. The study team (a
female gynaecologist {with 10 years' experience as
consultant, a physician, a pathologist, a laboratory
technician, a nurse, and female social workers) visit
ed the field camp and conducted the study. The
women who were found to have diseases were
offered treatment.
First, information was obtained on persona
details, socioeconomic status, perceptions and pra
ctices as regards gynaecological symptoms, past
experience of care and obstetrical, gynaecological,
and sexual history. The women then had a genera*
physical examination including speculum examina
tion and bimanual examination of the pelvis: un
married girls with an intact hymen had rectal rpther
than vaginal examination. The following labora
tory investigations were done ( apart from vaginal
specimens omitted in the never married ) : urine
and stool tests; haemoglobin; peripheral smear for
typing of anaemia and for parasites; VDRL test; sic
kling test with 2% sodium metabisulphite; urine
culture and antibiotic sensitivities when necessary
vaginal smear microscopy and gram stainmg; vagi
nal and cervical cytology with Papanicolaou stain,
culture and antimicrobial sensitivity of vaginal swabDiagnostic terms and entities were those in
the International Classification of Diseases, Sth
revision. Vaginitis was diagnosed when the vaginal
wall was visibly inflammed and the vaginal smear
showed at least 5 pus cells per high-power field.
When smear microscopy, gram staining, or culture
revealed no pathogenic organisms, it was labelled
vaginitis of unknown origin. Syphilis was diagno
sed when the VDRL test was positive in 11 dilution
or more. Pelvic inflammatory disease was diagno-
ssd when adnexae were palpable and tender on
vaginal examination, with or without restricted mo
bility of uterus. Jeffcoate's criteria were used for
various other gynaecological conditions.
Anaemia in females was defined as a haemog
lobin of 11-5 g dl or les. Iron deficiency was diagn
osed on the basis of hypochromia and microcytosis
in peripheral smear.
Vitamin A deficiency was
diagnosed by identification of conjunctival xeros s
or Bitot's spot. Sickle cell disease was diagnosed
by the sickling test, but homozygous disease and
trait could not be distinguished, in the absence of
el ectrophoresis.
n Gynaecological and Sexual Complaints
<nvz6yo)
Complaint
Frequency
%
88
60
3$
82
4~
32
J32
98
43
13-5
9-2
5.5
12.6
6.9
4-9
2Q.J
I5.I
3-6
69J
3
Vaginal discharge
Burning on micturition
Childlessness
Scanty periods
Irregular periods
Profuse periods
Amenorrhoea
Dysmenorrhoea
Dyspareunia.
Other
... Because of the sensitive nature of the cultu
ral norms of these traditional societies, we aimed
ata conservative 50% coverage of the eligible
women. In the event, 654 out of 1104 (59%)
turned up to participate and the investigations were
completed in all but 4. Although every effort was
made to persuade both symptomatic and symtomless
women to participate, selection might have arisen.
We therefore visited a 26% random sample-of non
participant women a; home to record their personal,
obstetrical and contraceptive histories, presence or
absence of gynaecological symptoms (vaginal dis
charge and menstrual disorders),and reasons for
non-participation.
k
The data were analysed by use of the SPSSPC package on a PC-XT computer.
RESULTS
The mean age of the 650 women was 32.11
years (SD 13 46), 92 (14%) were unmarried, 462
(71%) were married and living with husbands. 28
(4%) were separated, and 68 (11%) were widows.
Thus 551 women were married at the time of study
or had been in the past. 281 (44%) were farmers,
149 (23%) were landless labourers, 9S (14%) were
housekeepers. 21 (3%) had regular jobs, 46 (7%)
students, and 55 (9%) were in other occupations.
436 (68%) were illiterate; 84 (13%) had schooling
up to 4th standard, 52(8%) upto 7rh standard,
and 65 (10%) up to 10th standard, and 8 (1%) had
college education.
299 (46’0%) belonged to middle castes and
123 (18 9%) to lower castes; 138 (21*3%) were of
trible origin and 28 (4’3%) from nomadic tribes;
and 62 (9 2%) were of other castes or non-Hindu.
3
28 (4%) of the subjects had not reached
medarche, 468 (72%) were menstruating, and 154
(24%) had reached menopause. Tho mean gravi
dity was 3-99 (SO: 2’7.7) and mean parity was 3 75
(SD 2-74). 48 women were pregnant at the time
of study. Out of 462 women whe were married
and living with their husbund, 254 (55
were
using one of the following contraceptive methods :
condom 5, Copper-T'7, withdrawal 2, safe period 2,
pills 5, abdominal tubectomy 24, laparoscopy tubsctomy 58, vasectomy 151; thus female contracep
tive' methods were used by 94 at the time of study
and had been used by a further 29 in the past, totaj
123.
Table U-Chvacteristics of participants compared with 2S%
Random Sample of non-participants
Characteristic
Mean age (yr)
Gravidity
Gvnaecolbgical symptoms
VaginaTdischarge
Scanty periods
Irregular periods
Profuse periods
Dpsmenorrhoea
BOH in ever-married
Current use of female
contraception in ever-married
Participants Non-participant
(n 6yo) sample (n= 105)
32.11
3-99
43-3
24-5%
T2\6%
6-9%
" *9%
15-1%
37^/o
8-25%
26^
24^
18.2%
22.3^
4-^f<s
23^
52-^
A total of 360 women (55 3T%) had one or
more gynaecological or sexual complaints (.table I).
In addition, many complained of two non-specific
but related symptoms—low backache (197) and
lower abdominal pain (86). The characteristics and
symptoms of those who participated did not differ
greatly from those of the random sample of nonparticipants (table II). The-main reasons for nonpartipation were : no gynaecological complaints
27ZT05; “I am too ofd for such things" 17/105;
frightened of gynaecological interview of examina
tion 16/105, out of vrtlageat time of study 15'105;
unmarried, so did not want to be examined 4/105.
Premarital sex among the unmarried was
diagnosed when the hymen was torn and the
Table III—Prevalence of gynaecological Diseases among
women with and without gynaecological symptoms
(Excluding pain in lower Abdomen and Backache)
—
Symptomatic
Symptoms-free Total
DISCUSSION
With diseases
Without diseases
335
5
244
46
599
51
Total
f ■'
3^0
2^0
650
Table IV—Selected Gynaecological Diseases versus past 0^
present use of Female contraceptive methods in
ever married (n = 338)
Diagnostic groups
compared with 16 of 151 blaming their husband's
vasectomy. The numbers with intrauterine devices
(7) were too small for comment.
Contraceptive
history present
(n-123)
No (%)
Menstrual diseases
92 (74-8)
Sexual problems
16 (13-0)
Vaginal infections
120 (97^)
Cervical diseases
102 (82,9)
Pelvic inflammatory diseases 39 (49 o)
Contraceptive
history absent
= 435)
No (%)
202 (46.4)
28 (6.4)
352 {80.9)
292 (67.1)
1^)0 (23.0)
vagina easily admitted two fingures (girls and
women in this area do not use tampons), On this
evidence 43 out of 92 (36-7<%) Of the unmarried
girls had had sexual intercourse.
The most common non-gynaecological con
ditions found in the survey were anaemia (in 91%),
iron deficiency anaemia (83%) sickle cell disease
(7%), Vitamin A deficiency (58%), filariasis (12%),
pulmonary tuberculosis (2%), leprosy (10%), and
urinary tract infection (4%).
History of gynaecological examination was
used as an indicator of professional gynaecological
care in the past. Only 51 (7 8%) had such an
examination.
. ;
Table III gives the prevalence of gynaecolo
gical diseases in women with and without symp
toms. As an indicator of gynaecological diseases,
gynaecological
symptoms had a sensitivity of
59%,
a specificity of 90%, positive predictive
. value 99% and negative preditcive value 16%.
Table IV indicates that gynaecological disea
ses were more frequent in women with a contrace
ptive history. Of the 12 who had had tubectomies,
54 (66%) attributed symptoms to this procedure
In this cross-sectional survey, the prevalence
of gynaecological or sexual diseases (92%) and the
average number of such diseases per woman (3'6)
were remarkably high. Infections constituted 50%
of the burden-vaginitis, cervicitis, pelvic inflamma
tory diseases—and the rales would doubtless have
been even higher if we had used more refined tests.
Menstrual disorders from another big group and
infection of the genital tract may be a contributory
cause here. Fibroid uterus was very rare, and not a
single case of carcinoma was found.
The very high prevalences of iron deficrency
anaemia (83%) and vitamin A deficiency (58%)
were due to the poor economic status of the area
in general and of women in particular. The area is
endemic for filariasis and leprosy.
One noteworthy finding was that even symp
tomless women were very likely to have reproduct
ive tract disease (table IV). Symptoms are thus an
insensitive tool for screening in the presence of a
high prevalence rate. The negative predictive value
is also very poor. The gynaecological complaints
volunteered by women during history-taking were
offer, underestimates—espec’ally with regard to
vaginal discharge and menstrual troubles—because
of the concepts of normality. Thus ouly 98 women
complained of excessive pain during menstruation
but on careful inquiry 269 were found to exper
ience dysmenorrhoea.
There was some truth in the women's percep
tion that contraception causes gynaecological
troubles—there was a statistically significant asso
ciation between certain gynaecological diseases and
past or present female contraception. But this can
explain only a small proportion of the morb dity
since 78% of the ever-married women had never
used any such contraception, yet had a high preva
lence of diseases.
Unfortunately the diseases that do no kill
tend to be neglected. The non-neoplastic gynae
cological disec’ses come in this category, but they
could give rise to difficulty in occupational and
domestic work.
-
4
medico friend
166 circle
*•
bulletin
.
i t• r
. :.
'r .
i
August 1990
I
c
.
C ’
^OF SHAME-AND SORROW : WOMEN IN. SILENCE^.
'
•
Manisha Guptd\^. <
The facf that women's access to health
care is poor/ needs'nd proving. The shortcoming
of the [nc^n' Health- Care System, [which sees
women only as mother or potential mother is also
nowjmore or" less accepted by progressive per
sons .in ther people's4 health ‘ movement.
Even the
watered’down MCH pr a gram me does not effectively
reach out lopqor® ^working' cfass, especially rural*
women/tasi^ydaci'n thve infc bulletin of May, 1989*
fhaye'tried'tcfppifijou’fsome of the11 direct reasons
asvto'why rural ’women'do not receivegoodmaterC . v‘‘■pfdi.v t. . .3
-..‘v
ir.
nal health services.c
ev; C'lw osc/.T
itoey • c ccno .pedimfi lefcr. .
. Yo cbmpbi/ncT'th'e tragedy, ' tHe ^woman’ is
dofnbletei^ ^neglected1 by' public heath1 services.
Issues that are notdirectly'related to ' reproduction
and fertility are1, conveniently swept under the,
carpet.'1 Becaus^/1 oT the anti-nationalist policy of
pur Government,"infertility either a^ a physiological
pf psychological pfqbjerh does not merit due atten
tion,' yjqlenee Against‘ women, be it through wife
battering, harras'sment by husband's family, rape or
incest ts'either ,ooutright rejected of is candled in an
atmosphere of mistrust and anti-woman bias.
This article is based on some of the invisi
ble sufferings of wdrnen
es
• nm \’3v■ -it
that
require
sensitive
; % v-
• Ay/
:
handlingvby the medical profession/7 Naturally, all
problems are^RQt.covered her^^^Tha experiences
here are limited to^ obeTs own personal encounters
with the shame that rural women harbour towards
themselves and their own bodies, and the resultant
pain that they undergo. All the case studies prese
nted here are confined to a rural tahsil in Pune
District in Maharashtra State.
The most common ailments that women in
our area suffer from are white discharge, prolapsed
uterus, weakness, anaemia, aches—especially back
aches, menstural irregularity, genital and urinacy
infections, infertility and a variety of mental illness
such as depression, anxiety, hysteria, nervous bre
akdown. a death wish upon oneself hnd schizhophrenlas' r''
' ••
1
v: * :r
'
r'd
I- :
v <•./
Women wait for unbelievable long periods
of time before they seek medical aid for their pro
blems. One woman around 40 years of age, came
to the primary health centre with a history of leucorrhoea that started 15 years ago! Though she
may not be the rule, the nurses said that on an
average women come to the health centra after 6
months to three years of suffering where white
discharge is concerned. Sometimes women present
with a m:xed problem—menorrhagia for 10-15
days, followed by yyhite discharge. The cycle repeats almost every.mOnth^
Sometimes a coper,-/!-Jnd^cess white dis
charge, not.to mention heavy rnensmial flow. There
are instances:;.^vhere worpep als^^fp^get7 about the
copper—i insertion.5andMtus;.deiec|e>d inside their
codies when they/t^i^ei; for btEe|. •gynaecological
problems,
Sr Sable of
the PHC nano®;
.flFirmparous came
for her delivW^Sl^^a^^c&mpanied by her
•WO*
70 years old
;
This grandmother
Decame good friends with the nurse and on the;
third day confided to her about bleeding and how
hat was a constant source of embarrasment. When
he nurse said that an internal examination was
required, the old woman further confided that she •
lad a loop inside herd The nurse naturally was
greatly surprised.
It turned out that 40 years ago ,
when her last son was born a loop was inserted and
sh had never ^ome back to have it removed. Not
surprisingly, the nurse found out that the woman
was not only bleeding, but that "there was a frohy
black, foul smelling discharge, along with pus*. The
loop, .probably a Daikon shield^ was withdrawn
amidst great difficulty and pain* The nurse stron
gly recommended that the doctor should examine
ner, but the old woman staunchly refused. ’Through
all my deliveries, 1 have never let a male come close
to me, and 1 can’t be put to shame in the last few
years of my life". She said.
She walked away
with some vaginal pessaries and vitamin,, tablets.
One can't help suspecting that she may well have
been one of the many women who silently suffer
from cervical arcinoma.
:..
' r •' L
■’
\
Women who have delivered at home and
who have returned to work immediately after deli
very often suffer from prolapses—rectal or uterine,
according to the local health workers. They also
state repeated pregnancies as a contributing factor
Often untrained delivery attendants ( mothers,
neighbours ) get a woman in labour to bear down
unnecessarily during the first stage itself. Random
tears are not sutured in home deliveries and later
on in life, women suddenly realise that they have
a prolapse/ Our experience has shown that most
often women don’t seek any remedial treatment
for prolapses.
Unless they have trouble in a sub
sequent pregnency they silently continue to suffer
the discomfort
and
embarassment. A ter our
Mahila Mandal meetings, sometimes a women will
call us aside and then with tremendous shame wi'l
venture to tell us abaut her white discharge or pro
lapse. Often she has sought no medical treatment,
earlier. Sometimes, she has, but the white disch
arge continnes. The nurses in the health centre
have never, to date, seen a doctor treat both, hus
band and wife for white discharge. Women are
often given only oral treatment, due to the patients
aversion of having to introduce vaginal pessaries,
oneself. Thus, in course of time, she is reinfected
and the cycle continues, untill the woman gives
up in sheer helplessness. Wnen women come rep
eatedly with a history of vaginal discharges, health •
workers speak contempously about their bad hyegi- • •
ene and that intensifies the shame.
. .
Most women refuse internal examination
even by a nurse. This makes diagnosis difficult
and so often the doctor prescribes without having
had a chance to diagnose properly. The nurses
said that besides being shy of the doctor, consult
ant work of home, on the fields or on EGS sites
makes If very difficult for women to visit health
cetnrs. The only time when women ever come to
health centres, they said, wes during the summer,
when agricultural activity ceased. Some women
vyho have been married for 20—25 years have
never stepped out of the village, except to go to
their natal families, once a year. Those who live
in wadis (clusters) away from the village, come
into the village only 3—4 times a year mainly for
social or religious functions. Their menfolk bring
in the grocery and since they have work to do
througout the day, it is never considered necessary,
for them to leave except to go to EGS sifas, often
away froq the village. Thus during festivals, women
tend to come to the health centre in a "might as
well go there" kind of attitude. Obviously, they
don-t come back to continue a prolonged treat
ment.
.. t
Lack of access to safe abortions is also a
great health hazared for woman. Pre-marital and
extra-marital relations are very rampant here, as
2
they are everywhere else, and it is a distressing
sight to see a fifteen years old undergo an unsafe
abortion. Interestingly, when we were asking
women if a pregnancy detaction kit was a felt need
here, two women discreetly made enquiries about
such a facility
being immediately available, and
both of them were not cohabiting presently with
their husbands : one was widowed and the other
deserted.
Recently an unmarried teenaged girl was
being forced by her mother to undergo an abortion
at the hands of a local abortionist when she found
out that the daughter was pregnant.
The girl,
scared, confided in a nurse, who examined her and
told her that she was about four months pregnant.
After must councelling, the girl was taken to Pune
city and and an MTP was conducted at Sassoon
hospital.
Not everybody is as lucky. ’ Various
indigenous abortifacients are used - the danger
ous ones being mild poisons administred orally and
neem sticks being used to insert into the uterusThe efficacy of the less dangerous methods' is not
yet clear, because abortions are a stigmatised and
taboo topic.
Childlessness is another major cause of
trauma for women.
Whether the couple is infer
tile, whether the children are dead or whether only
daughters are born, the main brunt is borne by the
woman in question. Various traditional methods
are tried including visiting shrines and fasting to
fighting off the 'voodoo' allegedly performed by
another childless woman I A young woman who
had recently lost her only child was in servere psy
chological tension. She came with clear 'symptoms'
of pregnancy : amenorrhoea nausea and vomitting.
When She was examined, the nurse realised that
she wasn-t pregnant. On closer questoining, the
nurse found out that she hadn't even cohabited
with her husband for over six months. The young
women said that the parents-in-law didn't allow
their son to sleep with or even speak to his wife,
and having lost her baby, she was feelling very
lonely. She said "I m somehow hoping that I have
another baby".
If one sees the women who occassionally
get possesed by a wide plethora of malevolent
gods and godess, one can clearly see that a low
majority are childless women, deserted women,,
and post menopausal women, when a local exor
cist was asked to why there were such few "norm
ally cohabiting mother" in the crowd, she laughed
and said 'where is the time available to those
women ? When you lack something, you turn to
god."
Infertility, either of oneself or of husband
( after improvement in the latter case ) is thus a
cause of great concern, because women fight other
women.
Constantly suspicious of the motives of
other childless women, the woman, retatiates with
her own voodoo, and thus solidarity between two
victims is not possible
■ :
’
j
»•
iiq
Impotency of one's husband Is also borne
with shame and in silence/ Orfe woman, after twe
nty years of marriage confided In a health worker
and asked if There were any tablets available to
cure his inpotency. She had, to date, kept silent
but since no child was born, the in-law were now
coaxing their son to remarry. Another sixteen year
old women, extremely impoverished has just run
away from her husband's house, back to het natal
family. The husband is impotent and during the
two years of marriage, she was ill treated by her
sister-in-law because "she would disclose the fact
to someone I She had never been allowed to meet
her parents after the wedding for the same reason.
When she recently convinced her husband to under
go a checkup; which he did, the ^tftlaw threatened
to murder her.
Today the doctor is refusing to
give her the report, though he has orally said that *
the husband requires "correctional surgery", and
the in-law have now sent her a legal notice. They
have also been spreading rumours about her immo
ral behaviour' I
A forty year old woman, came to the PHC
with leucorrhoea. She was pregnant for the first
time. Curious, the nurse questioned her about
such a late conception. The husband, a perpetual
womaniser, has never cohabited with her. Only
during the past one year did he ever approach his
wife. "I don't care if a kitten or puppy is’born to
me", the woman said "but let me enjoy the bliss
of motherhood".
3
l
/
St]e begged the nurse not to repeat the story to
her husband, for fear t^rat (he would neglect her
crice again.
A rich landlord's daughter-in-law was also
be ng treated for heavy white discharge. She was
her husbands's first wife. The husband, a truck
driver, is notorious for womanising. Since they
were childless, he renounced, and now both wives
are simultaneously pregnant. She raved and ranted
about her husband's behaviour, yet she said that she
wajs glad to be pregnant.
The indignity that woman are subjected to
by their .husband's constant womansing also is a
helplessness that they have to go through alone,
woman often complain of 'burning sensation' after
intercourse. One woman, whose husband is biga
mous and an alcoholic asked if 'heat' from him was
being transferred to her. The local word for STD
especially syphilis is 'garmf or heat.
■
Another young girl narrated a horrifying
experience when a few days after her delivery her
beat r.er
her io
to ur
uncosciousness, because the
husband Dear
with]him. He said '*! haven't married
refused to sleep withjhim
you so as to worship you" and then he raped her,
He regularly visits prostitute women. She was
beihg treated for 'burning sensation'.
A CHG's damphter, barely eighteen years
of age was seven months pregnant, their husband
is j$ep driver and the in-law know about his woma
nising.
',Would we have got ourselves a stupid
daughter-in-law like you, if he had been straight''
they would ask her. Last year, she had a miscarrage
and now she is worried that her baby might be infe
cted. She herself had such a heavy discharge that
she was "even embarrassed to sit down for fear of
staining herself". The mother, being a health
worker, was keen not to send the girl to her hus
band until she was completely cured.
Within a
week of our conversation, however, the husband
came after her. and the daughter immediately retur
ned, saying that "it was the only way to stop him
from going to other women".
Not all women want to cohabit sexually
with their diseased husbands. Only they have no
*
choice at all. One woman saw some blood on,
husbands
genitals. The
husband, also a jeep
driver has two mistresses. This woman pleaded
us to ask her husdand not to touch her". I don't
care what he does out of housa as long as he leaves
me alone". She said that's easier said than done.
She is extremly worked up about his behaviour and
recently she had a nervous breakdown. She has
attempted suicide on three occasions. To make
matters worse, her husband is jealous of any male
that she speaks to and he viciously beats her, very
often.
Another
woman,
35 years of age and
whose children are now grown up has a similar
sorrow,
"My husband often brings other women
to my own bed to humliate me".
She has severe
gynaeological problems : periods stretching over a
fortnight each time, while discharge and buring
'like chillies' after intercourse. A drunkand, her
husband is also jealous by nature, and however
much she pleads of him to let her alone, he won't
listen.
Very few women, with clear symptoms of
STD approach the PHC for treatment. Also, when
widows or deserted women need contraceptives,
including sterilisation, they are. quite understanda
bly, reluctant to approach the Government Health
Center.
In one case, a childless deserted woman
came to are for a laparoscopy, saping that she had
two children and so she now wanted to get sterili
sed . Often, women from our area will go outside
to get a sterilisation performed as two widow rece
ntly did. They went to the neighbouring tehsil,
stayed at the PHC for seven days and came back
sterilised. Sterilisation however does not protect
a woman for contracting STD, and a few months
ago. a health worker found two women, one wido
wed and the other deserted, both suffering from
STD. Inspite of motivation, theyjefused to come to
the PHC for treatment.
The attitude of women, caught in an aw
kward situation, is quite ambivalant as far as the
health workers are concerned. "If we detect a
tricky pregnancy and help women to have discreet
abortions, they pretend not to recognise us after
wards".
(Ctdpage No, 8 )
4
Sexually Transmitted diseases : a growing menace
S V Morankar
All over the world, sexually transmitted
diseases (STDs) are a serious problem; India is no
exception. During the past two decades, the number
of diseases grouped under STDs has grown from
big five ( syphilis, gonorrhoea, chancroid, lympho
granuloma venereum and Donovanosis ) to more
than twenty. A number of clinical syndromes are
known to be secondary complications of STDs :
acute and chronic inflammations of male and
female genital tracts, genital cancers, infertility,
hepatitis and even AIDS. In 1985, over a million
cases were reported to have attended STD clinics
in India; their break- up is as follows : syphilis
( 30.5 % ), chancroid
( 25.9 % )
gonorrhoea
( 18.8% ) and non-gonococcal urethritis ( 13 3% )
Maharashtra has the dubious distinction of having
the highest incidence of STDs; Tamilnadu and
Gujarat are not far behind.
I propose to discuss briefly the origin and
transmission of STDs in end around Pune, and
various social end cultural factors
which have
contributed to an increase in the incidence of STDs.
These observations are based on an in-depth dis
cussion with four medical practitioners and the
functionaries of one primary health centre in Pune
district. These health workers have treated STD
. cases in their clinics in an area covering about
30,000 population.
Young adults, married as well as unmarried
aged between 18 and 25 years, form the biggest
group at risk.
Each practitioner sees and treats
atleat 3—4 fresh cases of STD per week. The
majority of cases contact infection
from one of
the three sources : urban, rural on contacts during
travelling.
The practitioners identified Pune as the
main urban source for the transmission of STDs
since a large number of prostitutes are available
there. Prostitution is also prevalent in urban centres
nearby. The rural youngsters, naive and gullible
as they are, often visit prostitutes when they come
to urban centres only to go back with STDs.
Strange though it may sound, the popular Ganesh
festival in Pune breeds an alarming number of
STDs almost year after year. So do Jairai and
Tamashas in villages when the STDs suddenly show'
a positive swing. People who have visited urban
prostitutes
and who have developed STD also
frequent these women in rural areas only to infect
them further. These woman in turn pass on the
disease to 'first-timer's.
Prostitution is not restricted to Pune city
and urban areas but with rural areas in Western
Maharashtra gettingly rapidly industrialised, it has
started spreading there too. As an ANM supervisor
with a long experience of working in PHCs told us,
the prostitutes are steadily migrating from Pune to
these virgin areas in search of -business'. What is
even more alarming is the observation of local
medical practitioners that the clandestine sexual
activities among widows, divorsed/deserted women
unwed girls and economically poor married-women
is showing a phenomenal increase. Indeed, the
sexual perversions have taken such an ugly turn
that sexual promiscuity and extra-marital relation
ships apart, incestuous relationships are also surfa
cing in rural areas.
The roadside dhabas and motels, where
truck drivers and their assistants usually eat their
mealsand retire overnight have a Is® developed as
new centres for prostitution and large number of
STDs owe their origin to these centres.
The local medical practitioner have obser
ved that STDs are no respecter of economic class :
rich and poor have been equally found to have
affected with STDsParticularly vulnerable are
unmarried adolescents. They develop morbid fears
about their potency—borne out of sheer lack of sex
education—and in orders to prove their manliness
or virility, they visit prostitutes only to come back
with STDs. Many a marriage here had to be post
poned because ef pre-marital sex-induced STDs and
the doctors had to prevail upon these youngsters to
undergo full treatment before marriage. Since the
parents are usually oblivious of these diseases in
their grown-up children, the doctors often have
tough time explaining them as to why they wish to
have marriages postponed.
5
Since, by and large it is males who get
themselves treated for STDs, the number of women
infected but untreated—is gradually swelling. The
health practitioners usually motivate married men
with STDs to have their spouses treated simultane
ously but* this seldom happens and hardly 1-2%
couples see their doctor for full treatment. To evade
embarrassing probing from the elders in the family,
STDs in women—all too often passivety contacted
are kept a closely guarded secret. And yet it is
invariably the wife who takes the blame.
Further, Garmi. as STDs are here colloquially
called, is usually attributed byr a mother-in-law to
her daughter-in-law's indulgence in "too much tea"
or "hot and spicy meals". The daughter-in-law is
generally forbidden, to sleep with her husband nor
is she permitted—at times even actively discou
discou-
.
This
unforraged—to go to a doctor to seek cure.......... . .........
piquant
situation
:
intratunately leads to a very
irreparably
broken,
new
marital relationships are
and
STDs
simply
extra-marital affairs develop
proliferate I
Repeated, and mixed, infections are comand
have been noted in as high as 25% cases.
k mon
Even such drastic advices as "next time you might
as well loose your penis" or "we will have to chop
off the diseased organ next time" fall on deaf ears.
Only> quarter of STD cases receive full treatment;
majority discontinue treatment midway through.
This ma\cause, and has already contributed to,
drug resis^o^^ccess to over the counter drugs
and antibiotics is easily possible. The repeat cases
seldom seVtheir doctors/health workers. Instead,
they would directly go to a chemist, manage to
hoodwink himoy showing an old prescription and
The inadequate and
thus would get self-treated.
j
i
s
obviously
not
without dangers
self-treatment
but there is little that the health workers can do to
stop it.
So what then is the solution ? The health
practitioners strongly feel that sex education to
adolescent boys and girls and students in their pre
college days should help. It might help boys resist
the temptation of going for a 'potency test', girls
won't easily go astray and the number of unmarried
mothers and unwanted pregnancies would fall too,
with a substantia! reduction in the number of
STDs.
®
S
I
!
is inadequately equipped to deal with violence ag
(Ctd. page 4)
A nurse said that sometimes they can
almost guess that a women patient has some grave
problem back home, but that it is not possible to
do anything about it,
"Women are suspicious and
afraid. They feel that we may misuse the infor
mation about their personal problemsoreventhat
co-incidently we maybe relatives of their husband s
families. They are also scared about the consequ
ences of speaking out their problems."
Women,
who are victims of stark violence already, are reluc
tant about speaking out for fear of "what can
happen between the four closed walls of their
homes".
a
aside, the nurse said "when
we are ourselves unable to stop our husbands from
beating us, we can hardly help patients."
A vicious circle of silence, shame and
sorrow is thus set into motion. The health system
ainst women, or with disorders that can't be cured
with quick medication.
who suffer can
On the other hand women
neither
speak nor approach the
health services. Shame towards one's body is not
restricted to leucorrhoea, or childlessness it is also
manifested through stigma of menstruation
child birth.
and
As principle actions in the struggle
towards their own liberation, it is only a progressive
organisation
of women
that can
give voice to
women's fear and shame, then proceed to question
the inadequency of the health care delivery sys
tem to hear out these demands.
It is only through
a forceful voicing of our problems outside of our
four
walls that can reduce our persistent fears
about what can happen to us inside them.
s s
6
rMME^U
Why Women Hide Them
Rural Women’s Viewpoints on Reproductive Tract Infections
Rani Bang and Abhay Bang
with the
Search Team
1 importance, 95
put white dis-
Gadchiroli is a remote
district of Maharashtra,
where we run a small nongovemmental organi
sation called Search.
Four years ago, through
a community based
study, we discovered that
gynaecological diseases
•were a major cause of
illness among the village
women, already’’bur
dened with poverty and
oppression. Since then
we have tried to develop
a programme for repro
ductive health care.
meetings and
jathaSy an attempt has been made to
create awareness and interest among
them regarding issues like Reproduc
tive Tract Infections (RTIs) and other
gynaecological diseases, unwanted
pregnancies and abortion, adolescent
health, sex education and reduction of
childhood mortality. In an area of 58
villages, we have trained community
based health workers like nurses and
Traditional Birth Attendants (TBAs)
to diagnose and treat RTIs apart from
giving related health education.
Sex and reproductive life is a very
private and secret matter in Indian
society. These illiterate rural women
have honoured us by sharing with us
their private lives.
Through our community based
study of gynaecological diseases, we
tant and common prob
lem. One woman said,
“Like every tree has flow
ers, every woman has
white discharge. Except
that it’s not soothing like a
flower? In the study of
gynaecological diseases,
we found that 75 percent
of women examined had
white discharge. I have
chosen to focus only on
women’s views on white
discharge as the major
manifestation of RTI.
These views were
found that 92 percent of women inter
viewed and examined in the two study
villages had gynaecological diseases,
half of which were RTIs. Only 7.8
percent of these women had ever re
ceived medical care for gynae
cological problems. Women had their
own world of beliefs and practices in
relation to RTIs. They had only mar
ginal interaction with the medical care
system.
RTIs cover a very broad field en
compassing many aspects of repro
ductive life. Women do not have any
medicalised concept like RTI. This is
an abstract concept for them. The real
ity for them is what they experience
and suffer. When 30 men and 32
women were asked to list women s
health problems in the order of their
sions with 60 women, interviews with
couples, interviews with 22 key infor
mants, especially TBAs, open ended
interviews of 65 women, and from the
perceptions of the 654 women exam
ined and interviewed in our previous
gynaecological study.*
Twelve synonyms are frequently
used in our area to describe white
discharge. This shows how important
a role it plays in the lives of women.
White discharge is experienced as
clothes getting wet or stained or
starched or passing white sticky dis
charge during urination or
defaecation, or by smell. A few
women said, “One feels as if bubbles
• RA. Bang ct al Lancet. January 14. 1989.
p.85.
_____
27
NUMBER 69
are coming out.” The profuse dis
charge is sometimes called “white
menstruation”. One TEA confided
that she goes around in the village,
and watches the hanging linen of
women. From the stains, she can de
termine who has white discharge.
White discharge is also diagnosed if a
woman is feeling weak for any reason
or-if the urine collected in a container
shows white sediment at the bottom.
Women have their own classifica
tion of white discharge into five cat
egories, each with distinct character
istics and different significance. There
is a hierarchy of seriousness among
them. One called pair, which means
blood stained discharge, is supposed
to be most serious and an omen of
death. This intricate classification
shows that the village people have
closely observed and thought hard
about white discharge.
The percQjved cause of white dis
charge is heat bursting out from inside
the body. This heat may be caused by
a woman having an inherently defec
tive constitution, or it may enter the
body through intercourse with an alcobolic or promiscuous husband. On
noticing white discharge, women of
ten conclude that their husbands must
have slept with another woman or
visited bhut khana
(haunted house),
which means the redlight area. If the hus
band does not have a
problem, the woman
is supposed to have
caught it from a pre
marital or extramari
tal relationship. Con
sumption of food sup
posed to be hot is also
said to cause or aggra
vate this heat. Unfor
tunately, most of the
nutritionally rich foods
such as milk, cream,
eggs, meat are sup- 28
posed to be hot and hence are avoided
by already malnourished women. It is
difficult to say whether this is a cul
tural conspiracy to keep women away
from nutritious food or a consolation
because they can’t afford to eat these
costly foods anyway. Twenty five per
cent of women, mostly those who have
used female methods of contraception
(specially IUD and tubectomy), said
that these methods result in white dis
charge. Weakness due to any cause is
also supposed to cause white discharge.
When there is profound weakness or
swapna vikar, that is, dreams of sexual
intercourse, or when the white dis
charge becomes chronic and does not
respond to treatment, then it is attrib
uted to witchcraft or black magic.
The site of origin of white dis
charge is believed to be somewhere in
the pelvis but independent of the uterus.
One TEA even said that there is a
separate sac (bladder) for white dis
charge.
Doctor’s Perceptions versus
Women’s Perceptions
When we first discussed among
ourselves studying gynaecological
diseases in rural women, a guest pro
fessor of gynae-obstetrics at John
Hopkins University remarked that it
was not a problem worth studying
because in his view, “Women may
continue to pass white discharge but
how does it matter? It is an innocuous
symptom like nasal discharge!”) But
how do rural women feel about this
symptom? The perceptions of this ex
pert and those of rural women about
the ill effects of white discharge are
diametrically opposed. Our commu
nity based study vindicated the per
ceptions of the village women.. In the
original gynaecological study, 654
women were asked “Is white discharge
a disease?” and 90.4 percent of women
replied “Yes, it is a disease and quite a
serious disease.” Women believe that
this is a chronic disease which drains .
energy and blood from the body and
leads to severe weakness and ulti
mately death. Women described 29
types of ill effects. The more impor
tant among these were weakness,
anxiety, and guilt feeling, pain, loss of
libido, dyspareunia and genital dis
comfort.
A woman comes to the clinic. I ask
her, “What is the problem?” She an
swers: “Weakness”. When, I ask her,
“Do you have white discharge?” She
almost always says “Yes”. (95 percent
of women with white discharge come
complaining of “weakness”.) The
perceived
relationshp between
white discharge and
weakness is so close
that they are used in
terchangeably. This
is probably for two
reasons. Women
strongly believe that
white discharge
drains off body en
ergy and leads to
weakness (kamjoori,
ashaktpana). This
beliefis rooted in the :
philosophy of Ayurved — the ancient life
p science of India,
MANUSHI
i
I
of women had gone to the modern
which emphatically states that semen aan khanyasathi^ (Did I marry you medical care system for treatment of
ka gynaecological diseases. How do we
is concentrated energy and its loss in only to feed you and rest?) or
san
gate
rand!
Dekhijayegi
tabyet,
ab
men leads to incapacitating weakness.
explain this? Non-availability of doc
to
chahiyer
(Bloody
woman
what
Loss of white discharge from a
tors in rural areas, cultural inhibitions
woman’s body is supposed to have a nonsense are you speaking? I shall in consulting male doctors for
see about my health later on. Right
similar consequence.
gynaecological diseases, lack of time,
This ‘weakness’ is an all encom now, I want sex.) Women complain, money and support contribute to a
passing term — it is physical, mental “Men don’t want to spare us a single very low proportion of women seekng
and sexual weakness. Thus the term night. They are very arrogant!”
One TBA and her daughter-in- medical care. But the major obstacle
weakness carries wider meaning than
is the reluctance of women to admit
is generally perceived by most doc law complained that the daughter-in- that they have white discharge. Thus
tors or health professionals. There is law had white discharge, loss of libido in our gynaecological study, 74.86
I another reason for the symptom of and dyspareunia, but her husband percent of women were found to have
white discharge being interpreted as would not listen. The mother re- white discharge but only 125, that is,
weakness. A woman often has a pro quested her son to avoid sex with his 22.60percent had complained of white
found sense of guilt and shame when wife but the son flatly refused and discharge despite careful enquiry by
she has white discharge. The woman retorted to his mother, who is a widow, the gynaecologist When probing
herself, her husband, and village "Tumhi navhata ka kela? Ata mala questions were asked why did these
community all may conclude that she san gate rand! Tule nahi bhetala tar women hide their complaint of white
had an extramarital relationship. The mee bee tasach rahu kay?” (Didn’t you discharge? Over half (60.1 percent)
husband scolds, “bhosadichi, have sex with my father? Now, since of these women said that they felt too
kanasobat nijal! asen mhanun asa you don’t get it, you want to deprive shy to tell the doctor as they thought
Jhala” (You woman with large vagina, me also?)
I might suspect their chastity, 25 per
White Discharge and RTIs
you must have slept with someone
cent of the women said that, as a
The community based study of doctor, I should have detected it my
else.) If the husband develops the
symptom first and the wife later, then gynaecological diseases in rural self, and 15 percent said I should have
the woman is supposed to have con women showed that out of553 women myself assumed it as most of the
tracted it from her husband. But this examined, 414, that is, 74.86 percent women have this problem.
is again shameful, because it is as a had white discharge,
Why Women Hide It
sign that the woman’s husband is not ’In' these 414 women, we found.
Because
of its perceived link with
89(21%)
I satisfied with her and hence his in • Cervical erosion in
promiscuity,
women try to hide it.
155(37%)
terest is wandering. Thus, white dis- • Cervicitis in
Sometimes
“
Sotafodat
nahin" — the
57(14%)
charge is always associated with guilt • Endocervicitis in
woman does not disclose it herself.
• Pelvic Inflammatory
feelings.
133(32%) Other women in the family, when they
Diseases in
White discharge is often accom254(61%) notice the stains on clothes while
| panied by a loss of libido ( akarshan • Bacterial vaginitis in
155(37%) washing, report it to her mother-inkami hate” — attraction becomes • Candida vaginitis in
law. Women don’t easily disclose the
less), discomfort and dyspareunia, • Trichmonas vaginitis in 71(17%) complaint of white discharge to other
17(4%)
I feeling of shame, guilt and anxiety. • Senile vaginitis in
women to try to prevent the news
Vaginitis
(unknown
origin)
23(5%)
Together with weakness these all re
When the question “When should spreading throughout the whole vil
sult in a disturbed sexual and marital
relationship. A woman pleads with a woman with white discharge seek lage.The hierarchy of sources of care is
her husband not to have sex with her treatment?** was asked in the group as follows. Home remedies are invari
I either because she does not have the and individual interviews, all the reably tried first on the advice of an old
desire or because she believes that spondents said that white discharge experienced woman or a TBA. Next
her husband would contract the dis- should be treated immediately as soon
comes
vaidu — the village
ease and would also become weak by as it11 appears because
uecausc if
n not treated, ..it —
-------- herbalist. If
having sex withher. But the husband progresses rapidly and may lead to there
there are
are sexual dreams and also
ser^s^mpS
and ultimately
ultimately sleeplessness
sleeplessness aalong
usually becomes furious and abuses serious
complications and
ong; wi 'v
her by saying something like "Tula death.
But
from
our
gynaecological
charge.then.t'ssupposedtobecaused
death. But from our t.
by witchcraft or black magic and hence
kaun keli? nusta zopun rahanyasathi study, we noted that only 7.8 percent
29
NUMBER 69
I
the help of a mantrik, a healer who uses for treating white discharge are far
witchcraft, is sought If all these fail more effective than the traditional into account. Hence, the approach I
developed by Search to de$I with re
and if the husband shows concern and remedies. Who knows the truth?
productive
health has attempted to
the family has resources, then a doc
Most of the women believe that
tor, generally a private practitioner, is their husband should also be treated evolve a programme with ^our com
consulted. Since there are practically simultaneously, as he could be both ponents—study of percep ions and
no female doctors or gynaecologists the cause and an additional sufferer practices of women and men, medical
in rural areas, internal pelvic exams of the illness. But___
_ husbands and epidemiological s udy of
usually
are not done and the diagnosis and refuse to seek care if they don’tTave gynaecological diseases in women.
treatment is based only on a descrip- symptoms. If men have a symptom of heaith education using methods like
tion of the symptoms. Even in trying urethral discharge, they get very up women’s awakening and hea 1thjatra,
and lastly the training of village-based
to explain the symptoms, there are set and seek treatment quite early."
health workers and TB As for diagno
communication barriers. A woman
Conclusion
sis and treatment of RTIs.
cannot describe her genital symptoms
Rural
women
in developing
Propagation of contraception in
openly to a male doctor so she speaks
countries are carrying an unbeliev womeniwith
‘ ' RTIs is addin; to the
obliquely in symbolic language. The
able burden of gynaecological dis distress. The poor women alreadyj are
doctors, trained in western medicine, eases, especially RTIs. A policy maker
being unaware of the hidden meaning at the Indian Council of Medical Re suffering from inflammed 'aginae.
of these subtle symbols, fail to appre search once questioned our statement eroded cervices and infections in and
around uteri. Imagine the agony they
ciate the wom
suffer and the
an’s real prob
badrepmationit
lem. Thus v/hen
brings to fam
she says she haar
\\
ily
planning
weakness, the
when
a breign
doctor treats her
body
like an
as a case of
IUD is inserted
anaemia, leav
in her under
ing her problem
such
(jondiof white dis
tions. Ely recharge
un
jecting Contra
touched
ception, poor
Women
women bf the
even have pre
Third
Wo rid are
ventive herbal therapy for white dis that gynaecological problems are a
sending signals to policy makers in
charge. The tender shoots of a tree major cause of ill health of women.
Delhi, Geneva. New York and Wash
called katsawari are consumed by “Ifrural women have white discharge,
ington — “No contraception is acwomen and are also given to their so what?” was his remark. Our study
ceptable without gynaecological
young daughters to prevent the of gynaecological diseases and the care.”
occurence of white discharge
in fu perceptions of women about tlieir
«------We professionals have tended to
ture.
■e. This practice is so widely preva- gynaecological problems show that reduce women
________
___ __ to,
’s health problems
lent that now it is difficult to find this such policy makers are wrong. It is an convenient, narrow programmes de
tree in the forest because its shoots unfathomed iceberg which can no pending on our expertise. Sometimes
are nipped at an early stage.
longer be ignored. White discharge is it is family planning, sometime:: it is
!
Women have described to us the number one health concern of
maternal mortality, and sometimes it
nearly 40 types of indigenous treat women. All of us must take note of
is abortion. Women’s lives know no
ments for white discharge. They are this and respond to it.
such compartments. That is why we
widely used and believed to be effec
RTIs in women is not a mere mi have repeatedly appealed to health
tive. But Shrimati Walabai, the oldest crobiological infection. It is intercon care providers, asking them not
to
and the wisest TBA in our area, nected with complex cultural factors. speak of just maternal health but to
confided to me that the modem medi The solutions for prevention and speak of women’s health, woman’s
cines given to them (TBAs) by Search treatment of RTIs take these factors total reproductive health.
□
io~
MAMUSHI
Oxf« /d
Textbook of
Medicine
Edited by
D. J. Weatheral!
Nuffield Professor of Clinical Medicine, University of Oxford
J. G. G. Ledfngham
May Reader in Medicine, Nuffield Department of Clinical Medicine, University of Oxford
D. A. Warrel!
Director, Wellcome-Mahidol University, Oxford Tropical Medicine Programme,
Faculty of Tropical Medicine, Bangkok, Thailand
Wellcome Reader in Tropical Medicine, Nuffield Department of Clinical Medicine,
University of Oxford
Oxford
Melbourne
Tokyo
OXFORD UNIVERSITY PRESS
1984
5.279
Syphilis
'Nonirritating'
g«nar|lil«d
»ymm«trica>
rash, many
systamic
signa and
symptoms
infectivity. The estimated figures for infectivity vary but is com
ply assumed to be around 50 per cent. After a single exposure
Jhe figure is nearer 25 Per cent'
Some control measures. The main source of case finding is the more
tensive use of serological tests for syphilis as already mentioned.
Another valuable control measure is contact tracing which is very
triable in different countries, but should be standard practice
everywhere. Its use across international borders should be de
veloped With proper safeguards to preserve confidentiality. Other
measures which should prove valuable are the education of the
voung without inducing anxiety, the educabon of doctors, and
encouraging regular check-ups of high-nsk individuals such as
homosexual men and prostitutes. The obligatory antenatal blood
rest for syphilis should continue. A more controversial suggestion is
to treat contacts of infectious syphilis epidemiologically m certain
situations, e.g. promiscuous individuals, known defaulters, and
those who may infect their regular consort if not treated.
These measures can be expected to uncover up to 75 per cent ot
all cases of syphilis.
Persistence of treponemal forms. Persistence of T. pallidum-nke
forms in the CSF, aqueous humour, lymph nodes, and other tissues
in penicillin-treated patients with late or late latent syphilis has
been reported from several centres. The same phenomenon is the
basis for relapses after penicillin treatment in borreliosis (see page
5 295). In some cases, the forms may have been non-pathogemc
treponemes or artifacts, but in others rabbit inoculation confirmed
them to be pathogenic T. pallidum. These treponemes appeare to
be fully sensitive to penicillin in animal experiments.
Their presence in the aqueous humour or CSF might be ex
plained by the low concentration of antibiotics in these locations.
This is not the case in lymph nodes and other tissues and as yet there
is no explanation for their persistence. As these cases are very rare
there appears to be no need to change our ideas about treatment or
prognosis.
The natural course of untreated syphilis. T. pallidum penetrates
the abraded skin and intact mucous membrane. Within hours it
becomes disseminated via the blood stream and lymphatics and is
beyond any effective local treatment. The incubation period is
traditionally given as 9-90 days but in practice it is around three
weeks (range: two to six weeks). The time depends on the size of
the inoculum, sexual practice, and hygienic measures. A single
treponeme leads to the longest incubation penod. The pnmary
lesion develops at the site of contact and heals m two to six weeks.
In a proportion of patients a secondary stage appears six weeks
after the primary lesion has healed but there may be an overlap of
the healing primary and the onset of the secondary stage. In some
cases the period between these stages can be prolonged to several
months. The main characteristic of the secondary stage is a general
ized, symmetrical, painless, and non-irritating rash. In about -U per
cent infectious relapses occur during the following year (range: one
to four years). In the rest, the latent asymptomatic period follows
and may persist for life in at least 60 per cent. In 30-40 per cent a
third late destructive stage develops. Its more benign form involves
only the skin, mucous membranes, and bones. In the serious form
the CNS, aorta, and other internal organs are affected. The major
events are shown in Figs. 1 and 2.
.
.
The course of untreated syphilis has been investigated in (he now
famous Oslo study (1891-1951) when almost 2000 patients with
earlv syphilis were left untreated and studied. Approximately 1000
patients were finally analysed with the following results: relapsing
secondary syphilis'was observed in 25 per cent: cardiovascular
syphilis was diagnosed in 10.4 per cent: CNS lesions in 6.3 per cent:
and gumma of the skin, mucous membranes, or bone in 16 per cent.
A total of 23 per cent died as a direct result of syphilis. Senous late
syphilitic complications were twice as common in men than women.
This study is open to several criticisms. The study was completed
before all the patients had died and thus some late complications
Painless sore"
regional
adenopathy
Infection
1___
3/52
Incubation
2-6/52
____
1
----- -------//-------4-6/52
2-6/52
2 ¥•»'«
Secondary aypbili*
Primary syphilis
♦ or —
Serology
__
- —
Infectious
relapse in 25%.
especially in
first year
++
4.
Earty latent
Syphilis*
** Lata latent
+or + +
*
— Infactiou* ----------------- ---------- —
•Pregnant women may inlact tha fatua in early latency and during the early part of late latency
Fig. 1 The course of untreated early acquired syphilis.
Law »w*
oaun •> SOS a
M M*r <*•
poll n— faTOMav P°*» <
•r
MHM
I
Cl-egoorlw wy* M
eowoi <<Z<i
|M« lO-livowM
t 1 •- — O 00.01 IWH"«T
UH me oo•> cyao ior'io.
WI*->
Fig 2 The course of untreated late acquired syphilis.
Asympiomadc neurosyphilis is present in 20 per cent and 20 per cent ot
these develop clinical neurosyphilis.
Cardiovascular syphilis starts subclinically many years earher and when
clinically apparent, it is in fact in an advanced state.
Prognosis: Gumma heals spontaneously in a few years. Cardiovascular
syphilis is usually fatal without treatment. Neurosyphilis: general paresis
has a poor prognosis without treatment, meningvascular syphilis rcmmonly responds well to penicillin, tabes progresses slowly but penicillin has no
obvious influence.
Overall mortality of untreated syphilis: 20-30 per cent.
may have escaped inclusion. The study took place at a time when
many patients died young mainly due to tuberculosis and once
again late complications may have been underestimated. Finally,
the disease was already changing as noted elsewhere and the change
was particularly marked in the incidence and seventy of the late
stage If a similar study could be undertaken at present, the results
might be quite different, and the Oslo study is by now of greater
historical interest than of practical value i* predicting the fate of
patients with untreated syphilis.
In the more recent Tuskegee study of Negro males with latJnt
syphilis it was found that one third died of late syphilis, mostly due
to cardiovascular lesions. In post-mortem investigations aortitis
was present in 40-60 per cent, far in excess of the clinical diagnosis
supporting the view that the cardiovascular lesion is-the most
important and lethal late syphilitic complication. Though the death
rate directlv attributed to late syphilis is around 30 per cent in
several studies, the incidence may be higher as there is some
evidence that the patients are more prone to other diseases includ
ing hvpenension. In all the more recent reports the incidence or
CNS svphilis and gumma is lower than in the Oslo study . confirming
that a change is taking place in the evolution of the disease.
Clinical features
briehued margin. It is not usually secondarily infected, a feature of
all open syphilitic lesions of any stage. The reason for this might
repay investieations. T. pallidum can be demonstrated in theserum
from the sore which is easily obtained after slightly abraidin the
base. In heterosexual men the common sites are the coronal su cus.
the glans, and inner surface of the prepuce but may be found on the
shaft of the penis and beyond. In homosexual men the ulcer is
usuallv present in the anal canal, less commonly in the mouth ( big.
4) and genitalia. In women most chancres occur on the \ulva the
labia, and more rarely the cervix when it is liable to be overlooked.
Infections
5.230
syphilitic until proven otherwise, especially when they are solitary
and painless.
,,
,.
Genital lesions which must be differentiated from primary syphi-
1 Genital herpes (see page 5.327). which is much more common
than svphilis in either sex. It is characterized by a crob of painful or
irritating vesicles which develop into shallow erosions. In the first
attackk there is also painful inguinal adenitis.
2. 'Traumatic
__________ sores.
“ These are painful, irregular and may become
secondarily infected.
y^rosive balanftis. These are inflammatory, irregular erosions
which may become purulent in the uncircumcised.
are macules or occas ionally ulcers
4. Fixed drug eruptions.,. These
--------------following various drugs, especially tetracyclines.
5. Chancroid (see page 5.305). This is mostly seen n the tropics,
_
presents as painful, superficial, ‘soft chancre . which is often mul
tiple with painful suppurative regional adenitis.
Other conditions which may have to be considered are scabies,
Behcet’s syndrome, granuloma inguinale, and lymphogranuloma
venereum.
Fig. 3 Large |
dary infection.
sore. Note the even shape and the absence of secon-
Fig. 4 Healing primary sore of the lip with some
induration around it.
Extragenital chancres usually involve the lips when they become
large and associated with some oedema, other sites are the mouth
buttocks and fingers. The regional lymph nodes are invanab y
enlarged’a few days after the appearance of the chancre and with
genitfl sores theyare bilaterally involved. The lymph nodes are
painless discrete, firm, and not fixed to surrounding tissues.
P Atypical primary sores are not uncommon and depend on the
size ofPthe inoculum and the immunological status of the Pat>ent,
plpulVandKn^ah^
tain numerous treponemes, a depletion of lymphocytes, follicular
hyperplasia and histiocytic infiltration. If T. pallidum cannot be
recovered from the primary sore, it may be possible to demonstrate
it from the needle aspirate of the regional lymph node.
Differential diagnosis. All genital sores must be regarded
Secondary syphilis. The lesions are numerous, vanable, and
affect many systems. Inevitably there is a symmetncal non
irritating rash and generalized painless lymphadenopaihy. Consti
tutional symptoms are mild or absent; they include headaches,
which are often nocturnal, malaise, slight fever, and aches in.jo.nts
and muscles. The rash is commonly macular, pale red and some
times so faint as to be appreciable only in tangential light. It may be
papular and sometimes squamous (rig. o).. Pustulaf
—-- - and necrotic
rashes are rarely seen in temperate climates but still occur in
tropical regions. The later the secondary rash develops the more
exuberant it becomes. The distribution of the rash can be of grea
diagnostic help. It usually covers the trunk and proximal limbs, but
whfn it is seen on the palms, soles, and the face, syphilis _shou d
always be high on the list of probable causes (Figs, 6 and 7). In
warm and moist areas such as the perineum, external female genita
lia perianal region, axillae, and under pendulous breasts the
papules enlarge into pink or grey discs, the condylomata lata, which
are highly infectious (Fig. 8). Mucous patches m the mouth and
genitalia are painless greyish-white erosions forming circles and
Ires ('snail-track ulcers’). They too are very infecuous.
Meningtsm and headache are due to low-grade meningitis wh ch
can be confirmed by a raised cell count and raised protein m the
CSLess common lesions include alopecia and laryngitis. Syphilitic
hepatitis is usually associated with a marked nse m serum phosphatafe. There are non-specfic inflammatory changes in liver biopsy .
material which are quite unlike those found in viral hepatitis. A
nephrotic syndrome may develop and glomerular immune-complex
"^P^minVh^bones, oft^worse at night, is usually due to periosti
tis Uveitis may be seen both in secondary and tertiary syphilis.
In about one fifth of patients recurrent infectious episodes occur
especially during the first year after the secondary stage.
All these lesions disappear spontaneously and leave no e'lde"ce
behind. It was repeatedly suggested in the older litera ure tha
extensive skin lesions had a protective effect and that late lesions. o
the CNS or aorta were less likely m such cases. It wtis belies ed that
this was due to elaboration of significant amounts of protective
antibodies by the skin lesions but no formal proof of this interesti g
idea has been presented. If true, one might further speculate tha
the extensive and prolonged skin lesions so prominent in all t\ pes of
non-venereal syphilis may be a factor protecting these patients from
the severe complications of the late stage.
’: with
Latent syphilis. By definition the patient is asymptomatic
is <arbitnormal CSF findings but positive serology for syphilis. It
It is
rarily divided into early and late latent syphilis. Infectiousness does
not stop with the advent of latency as women may continue to gi
5.281
Syphilis
.'■'W
O'W
Km/wlfft
• ?
si
(a)
Fig. 6 Secondary papulosquamous r<jih of the soles.
(b)
Fig. 7 Secondary rash of the palms.
(c)
Fig. 5 (a) and (b) Secondary papular syphilitic rashes; (c) Late secondary'
early tertiary papulosquamous lesions.
birth to congenitally infected infants during the early latent stage
and for at least two years into the late latent stage. Approximately
60 per cent of patients remain latent for the rest of their lives, the
only evidence of syphilis being positive serology with a usually low
titre. The rest develop clinical late syphilis but autopsy studies
indicate that a higher proportion has subclinical infection especially
of the cardiovascular system.
/oV'uaB''"’'
!o (
and
; d
Lt DOCUMeNTAT>ON J \
V'* V
hNIT
7 'k //
inieu(iuu»
Late syphilis (tertiary syphilis). This includes late latent syphilis
already referred to. benign tertiary syphilis, involvement of viscera.
the CNS. and the aorta. •
Benign late syphilis. 1. Cutaneous gumma. The gumm; is a chronic Granulomatous lesion which is usually single but ma \ be mul
tiple or diffuse (Fie. 9). Histologically there is central necrosis with
peripheral cellular infiltration of lymphocytes, plasma cells, and
occasional giant cells with perivasculitis and obhteratmg endarteritis. T. pallidum is present and can be demonstrated by rabbit
: painless
inoculation. Clinically it starts as a slowly progressiv
.
nodule which becomes dull red and breaks down into one or severe,
indolent punched-out ulcers. The base has a wa< h-le?.ther
appearance and is remarkably free from secondary mfeetior. (Fig.
10) It often resembles other granulomatous condition,,. It
st Jheals
cab
slowly from the centre, which may become depigmented1, whilst
wmlst the
periphery shows hyperp.gmentation. Eventually a pape r-thin
-thm scar
forms This combination of pigmentation, depigment.ition at.d
aZph.c scars can be of considerable retrospect.ve diagnostic help.
The sites preferentially involved are the face, legs, buttotks upper
trunk, and scalp. The process may be more superficial produemg
papulosquamous lesions which include the palms and soles. It too
heals with the typical scars already described.
*
T
Fig. 8 Condylomata lata.
-1- r "• *
•'0
|||p
tJ
1
> . •' V®
y>.-. i. •
Fig. 9 Multiple gummatous ulcers. This is a typical site.
.
Hg. 10 Single gumma. Note the punched-out ulcer and absdnce of secondary infection.
2 Mucosal gumma. These are most commonly jeen in the
oropharynx and involve the palate, pharynx, and the m sal septurm
They tend to be destructive causing perforation of the hard pala
and the nasal septum. In the pharynx and lary nx they tend to lead to
severe scarring. The most serious lesion is the diffuse
infiltration of the tongue leading first to a general swelling
5.283
Syphilis
3 Laie syphilis of bones. Osteoperiostitis of long bone““c’l^
, lhen due to loss of papillae to
pal
elsaiTFig.^)3 Penicillin has no effect on the progress of
glossitis at this late stage.
^'Differential diagnosis. 1. Mucocutaneous gumma. Jhe super-
&SSSSS81SK
rosy^^L^m^gu^eJymphl^
rinciple: A
were
“AV'riSK 5
I .J
Fa
b:
■
.r'
5^7-
infection but there was no further progress, bi p y
an epithelioma.
n!1(jent, with ulcers or nodes of the skin
Sis
ESelfc “b°^S.'.‘2kf.o.y. UM.<
syphilis^xcept Pinta give nse to similar lesions.
••r' ^SSS
visceral syphilis. This is not common -d
vanable. Late syphilis may involve the liver, eyes, stom
and testes.
..
ive rise t0 irregular
1. Liver. Multiple gummata of the b e g
mptomatic.
hepatomegaly (‘hepar lobatum )•
^1 ood vessels
Symptoms may result from pressure on bile duos o b o
, <
iibbib II
Fig. 11 Late syphilitic glossitis, early stage
but the available data are too scanty to
JSiy mav some.
~':=S::=5===
SyP?""or multiple gummata are
are rare
rare and respond to
trT“. Gummatous
duce ^^^'"c^see'n^y us penicillin had no effect.
V Paroxysmal cold haemoglobinuria. Syphihs is a rare cause of
this haemolvtic anaema (see Section
lat£
even more strongly in this section.
Fig. 12
Syphilitic leucoplakia of the tongue; premahgnant.
5.291
Syphilis
concentration reached is low and does not give. a useful
j., per
.1
££!-«•
per cent
Amative drugs ^"^^"Jsome of their drawbacks, notably
^^^X^brain and in the fetus are briefly
mentioned in the table on treatment.
men'
me tided treatment for syphilis
Table 2 Recom
1
Treatment
Diagnosis
aqueous procaine penicillin G 900 (XX)-^
Primary, secondary, latent
units/day x 8 days: some advise 1 million
syphilis and early
units/dav x 8 days i.m.
re-infections
If allergic to penicillin: ery thromycin
stearate 1 g twice daily x 14 days or
tetracycline hydrochloride 2 g daily
x 14 days
.
If pregnant and allergic to penicillin.
erythromycin as above
mptomatic aqueous procaine penicillin G 900 (XX)
Asymptomatic or sj P
units/dav x 14 days i.m. or aqueous
neurosyphilis*
penicillin G 12-24 million units/day
x 10 days i.v.
If allergic to penicillin: erythromycin
stearate 1 g twice daily x 30 days or
tetracycline 2 g daily x 30 days
aqueous procain penicillin G 900 000
Cardiovascular syphilis> or
units/dav x 10 days i.m.
cphilis
’
t
benign tertiary s< ' "
If allergic to penicillin: erythromycin or
tetracvciine as above
aqueous penicillin G 50 000 units/kg
Early congenital syphilis
x 10 days i.m. (use only penicillin in
(including suspe:ted early
coneenital syphilis). If mother recewed
congenital syphilis)
erythromycin during pregnancy, treat the
infant with a course of penicillin
aqueous penicillin G-dose according to
Late congenital syphilis
age and equivalent to acquired syphilis of
the same stage
0.5% prednisolone eye drops. 1 drop 1-2
Interstitial keratitis
hourly until condition controlled
penicillin as for late stage
Optic atrophy (cc ngenital or
acquired)
penicillin as for late stage + corticosteroid
Eighth nene deafness
penicillin as for the appropriate stage
Iridocyclitis (earl' ; or late)
+ 1% atropine eye drops; consult
Syphilis of the tcfngue
ophthalmologist
penicillin as for late syphilis and consult
ENT specialist for regular follow-up
SsESHSSSS
• In patients wii h gumma of the laryr
paresis, and cardio c
heimer reaction by "
the day before injection
t in patient diagnosed
surgeon
from the
..............
osual s'eno^aor '-aew .
segment)
ucat . bcfore glv,ng p^dn,,.
SeFt t”;
Or;:S,,pneenicillin has several advantages over other ^nici^
suks K is st^being Jed for venereal syphilis in a few centres.
Penicillin reaction. All patients
should be hept in the clinic
15 -
wdi wjthin thjs period
must be readily
adrenaline solution, syringes anti
population in the UK are ai
g
P
childhood infections It is qmte comm0
penicillin must not be
b
problems
M
The patient becomes unconscious. stoPs
A fata| ojnpulseless. Very rarely the patien i
loo'ooo injections,
come is estimated to occur o
Datient feels faint with acute
In the more
liable to last one to two weeks.
reaction when urticJna
ess •■=«»”«- * srxss
si: sssst. .HP
recurrences are otherwise
„
»
an injection and
J! EleSSXSS'SS.. —U iPi«a longer peri
to repeat the
of penicillin -y
for 7-10 davs
non. It passes off sPonta"e°^,; ;(,acf,On The patient is laid flat
E head dowi Blood pressure and pulse are momwith
feet
up
and
head oo
i. moo (0 5-1Pelops.
0 mi) is 250
given
tratOred ^^XtX^onc^p^m
mgir im.-
muscu arls "'tb°u™[er is administered by slow mtravenous
n0P I on iJrasenous hydrocortisone may also be med (Efcone-
Gonorrhoea
y urological tests for syphilis should be taken at the outset and again
/
or three months later.
[ Oropharyngeal gonorrhoea is more common in homosexual men
j than other groups of patients and throat cultures are the only means
( to make this.diagnosis.
Tficomplicated gonorrhoea in females. The commonest sites in
volved ire the endocervix, followed by the urethra and rectum; the
lafterl'an be the only site yielding gonococci. Before puberty the
vaginal epithelium can support the growth of gonococci but after
puberty the fornices may be the only area of the vagina capable of
i being infected; however, there is no consensus of opinion on this,
jg Trichomonas vaginitis is commonly associated with gonorrhoea
] when the profuse discharge may overshadow gonococcal infection,
f therefore patients with trichomoniasis should be carefully screened
. for gonorrhoea.
Clinically, at least half the women have no symptoms and little or
nothing abnormal is seen on examination. The rest have a variable
’ discharge which is not characteristic. Some patients complain of
dysuria and some have proctitis. The majority of women seek
medical attention because their sexual partner has gonorrhoea.
■ Screening women at risk for gonorrhoea is of proven value in
‘J detecting and treating asymptomatic carriers and thus reducing the
infectious pool.
r Local complications. Occasionally the paraurethral glands (Skene’s
| glands) are infected. More important is involvement of Bartholin’s
’(glands producing unilateral Bartholinitis. The gland and its short
Jduct is situated in the posterior third of each labium majus. The
I duct becomes infected and often obstructed when an abscess forms.
| It is seen as a forward projection of the vulva and the inflamed mass
eventually becomes fluctuent and will burst through the inner surface of the labium minus unless the patient can be treated.
’ «: Vulvitis is more characteristic in children with gonorrhoea. Signs
I of rriild trigonitis may be present.
Pelvic inflammatory disease (PID).This is the commonest and most
important complication of gonorrhoea in women. Gonococcal PID
appears to be much more frequent in the USA than in the UK,
possibly reflecting the differences in the incidence of gonorrhoea in
the two countries. Gonococcal PID is more readily recognized than
the non-gonococcal form and is estimated to occur in 10-15 per cent
of untreated women with gonorrhoea. Whether this estimate is
correct is uncertain when one recalls that more than half of women
with gonorrhoea are asymptomatic and may not seek medical
advice and an unknown number have minimalPID which is unsus
pected and discovered by chance during investigation for infertility,
tn a proportion of women with chronic vague lower abdominal pain
due to PID, clinical examination is unhelpful and the diagnosis can
°niy be made on laparoscopy.
The infection ascends from the cervix through the uterus to the
mucosa of the Fallopian tubes which it colonizes, producing a
purulent exudate which accumulates and mav spill into the perioneum. The Fallopian tubes enlarge and become oedematous.
the infection is not checked early on, the mucosa of the
is irreversibly damaged. This acute salpingitis is the basis of
^llnicQl features are more clear-cut than in non-gonococcal PID
k sudd^C 5
and
disease is usually more acute. The onset
L Lower abdominal pain and tenderness which is often bilateral.
• Reflex spasm of the lower abdominal muscles.
Fever which is usually over 38 °C.
4- Leucocytosis of over 20 000/ml.
ar
onset which commonly occurs during or immediately after
CapePOd which may be more severe and prolonged than usual and
n be regarded as already part of the illness.
fOss Examination reveals marked tenderness in one or both iliac
5.311
7. At pelvic examination, movement of the cervix from side to
side induces pain in both tubes (unilateral infection is unusual).
8. Bimanual palpation of the lateral fornices elicits severe pain
and at a later stage when a tubal abscess has formed, the tubes can
be felt as smooth sausage-shaped structures, and later still if pus
collects in the pouch of Douglas, this too can be felt as a boggymass.
There are, however, a number of patients in whom symptoms
and signs are indefinite and the diagnosis can only be made by
laparoscopy. The gonococcus may be isolated from the cervi • and
other genital sites but this is not always the case. If there are
grounds for suspecting a gonococcal aetiology e.g. if the sexual
partner had gonorrhoea recently, one should treat without de lay.
Luckily if the patient is diagnosed as non-gonococcal PID when in
fact the gonococcus is the cause, the treatment is likely to include
antibiotics which are effective in both types.
Treatment. This is essentially medical: (a) bed rest until fever and
pain have disappeared, which means admission of most patients to
hospital; (6) penicillin in large doses. Details of drug treatment are
given in Table 2; and (c) watch for bowel obstruction in the early
days.
Generally the patient improves in 48 hours of antibiotic therapy
and should be clear within two weeks. If there is no rapid response
to medical treatment, the patient should be re-assessed in consulta
tion with the gynaecologist.
Surgery is rarely needed. Indications are: (a) doubt about the
diagnosis. Especially when appendicitis cannot be excluded, lapar
otomy should be performed. If salpingitis is confirmed, the abdo
men is closed; (b) when rupture of a pyosalpinx is suspected; (c)
intestinal obstruction; and (tf) development of a pelvic abscess
which should be drained early to reduce the incidence of severe
chronic PID.
Late complications. These are more common when treatment has
been delayed or was inadequate and in severe bilateral infection.
They include reduced fertility, infertility, greater tendency to tubalpregnancy, recurrence of salpingitis because the damaged mucosa
is non-functional and cannot keep the tubes cloar; the infections are
no longer due to the gonococcus which has been eliminated during
the original course of antibiotics. Chronic PID. sometimes with
acute exacerbations, is essentially characterized by chronic lower
abdominal pain and deep dyspareunia. If such a patient fails to
respond to repeated courses of antibiotics, radical surgical
clearances may have to be considered.
Differential diagnoses include tubal pregnancy, acute appendici
tis, acute pyelonephritis, infected ovarian cyst, septic abonion.
endometriosis, intestinal obstruction, and non-zonococcal salpin
gitis.
Oropharyngeal gonorrhoea in both sexes. Infection at this site is
getting more common due to an increase in orogenitai sexual
contact especially in homosexual males where incidence figures of
10-20 per cent have been reported. It is usually asymptomatic
though some patients have signs of pharyngitis or tonsillitis. The
diagnosis rests on a positive culture.
Disseminated gonococcal infection in both sexes. The incidence
varies greatly in different regions of the world. It is uncommon in
the UK and frequent in the USA. Women, especially pregnant
women, are slightly more often affected than men. The gonococcal
strains responsible differ in important respects from other strains by
being exceptionally sensitive to penicillin and to the complement
mediated bactericidal action of normal serum and bv belonging to a
limited number of autotypes. These strains are frequently associ
ated with asymptomatic gonorrhoea in men. Host factors are also
involved as strains causing disseminated gonorrhoea do not usuaih
gi\e rise to disseminated disease in sexual contacts and in some
patients a deficiency of the sixth, seventh, and eighth components
of complement is present.
Clinically there is a wide spectrum of symptoms ranging from the
5.313
Gonorrhoea
Table 2
Treatment of complicated gonorrhoea
Treaimem
f Acute gonococcal PID mild
2. Acute gonococcal PID severe
3 PID in patient allergic to penicillin
Comment
procaine penicillin 2.4 million units i.m.
plus
probenecid 1.0 g followed by oral ampicillin 0.5 g q.i.d. x 8
days
none of the treatments used in gonococcal
aqueous crystalline penicillin G 10 million units/day i.v. until
improving (usually 48 hours) then: ampicillin by mouth 0.5 g ■ PID are ideal
q.i.d. x 8 days
a case can be made for giving tetracycline as
or
well as penicillin in the treatment to deal
procaine penicillin 2.4 million units b.d. until improving
with mixed infections of gonococcal plus
(approx. 48 hours) then ampicillin as above
non-gonococcai PID
cephalosporins:
cross allergy with
spectinomycin 2 g or cefuroxime 2 g i.m. t.i.d. until marked
penicillin in about 5%
improvement followed by doxycycline 100 mg t.i.d. x 8 days
or
co-trimoxazole tabs. 2 t.i.d. x 8 days
or
4. Chronic severe PID
5. Perihepatitis
6. Bartholinitis
erythromycin lactobionate 600 mg i.v. t.i.d. until marked
improvement followed by erythromycin stearate orally 500 mg
t.i.d. x 8 days
if repeated courses of antibiotics are ineffective radical surgical
clearance should be considered but with every effort to save at
at least part of an ovary
as for PID which is commonly present
ampicillin 0.5 g q.i.d until resolved; aspirate if abscess has
formed; if that fails, marsupalize
7. Disseminated gonorrhoea, mild
ampicillin 3.5 g orally
plus
probenecid 1.0 g orally followed by ampicillin 0 5 g q.i.d.
x 8 days
8. Disseminated gonorrhoea, severe
aqueous crystalline penicillin G 5-10 million units/day i.v. until
improved (usually 48 hours) followed by ampicillin 0.5 g orally
q.i.d. x 8 days
treat as early as possible to prevent abscess
formation
highly sensitive to penicillin: if clinical
picture suggests disseminated gonorrhoea
but the organism is not isolated, treat just
the same: prompt response supports the
diagnosis
or
benzyl penicillin 1.2 million units i m. q.i.d. x 2 days followed
9. Disseminated gonorrhoea but patient
a’lergic to penicillin
10. Gonococcal meningitis or
endocarditis (may be part of 9)
11. Acute gonococcal epididymitis
12. Urethral stricture
Table 3
by oral ampicillin as above
doxycycline 100 mg t.i.d. x 8 days
or
co-trimoxazo!e tabs. 2 t.i.d. x 8 days
crystalline penicillin G i.v. 10-20 million units daily until clear
ampicillin 0.5 g orally q.i.d
until resolved
or
(average 7-10
doxycycline 100 mg t.i.d.
days)
or
co-trimoxazole tabs. 2 t.i.d.
should be under the care of the urologist who may decide to
treat conservatively by regular urethral dilatation or by plastic
restorative surgery
highly sensitive to penicillin
if ambulant, to wear scrotal support during
the day
Treatment of gonorrhoea in infants and children
Diagnosis
Treatment
Comment
1. Gonococcal ophthalmia neonatorum
locallv with penicillin eye drops (10 000 units ml) at once and
then after every feed
plus
procaine penicillin 300 000 units/day i.m. x 5 days
procaine penicillin 3(X) 000 units day i.m. x 5 days
isolate infant with mother to prevent cro's
infection of other infants: start treatment
without delay: treat mother and trace and
treat her sexual contact
treat mother and trace and treat her sexuai
contact
test and treat the parent or person
responsible for the infection
2. Gonococcal arthritis neonatorum
3. Vulvovaginitis of girls under the age of
puberty
ampicillin svrup or paediatric suspension 250 mg t.i.d. x 5 days
in children under 10 years:
over 10 years: 500 mg t.i.d. x 5 days
. 5.314
Infections
are Gram-negative and for final identification the carbohydrate
fermentation test, preferably the new rapid method, is necessary.
We also suggest that screening for fi-lactamase production should
be routinely employed to allow speedy contact tracing and
appropriate treatment of all patients and their contacts infected
with p^lactamase-producing strains.
Delayed fluorescent antibody staining (DFA). Staining smears
from suspected colonies provides another method of identifying
gonococci but is complex and requires many safeguards to be
entirely reliable. For these reasons it is not entirely satisfactory for
routine work.
Results incorporating all these procedurescan be expected with
in ihree days.
. vAntibody sensitivity tests should be performed periodically to
recognize sensitivity changes in a community; If any hitherto suc
cessful treatment fails to cure 95 per cent of uncomplicated gonor
rhoea a change of treatment is indicated.
Serum tests for gonorrhoea. The GCFT and many newer serological methods have not much to offer in routine laboratory work.
meningitis and endocarditis which are potentially fatal diseases. In
gonococcal endocarditis the valves may be rapidly destroyed and
valve replacement may become necessary.
Some control measures. Measures which are of proven value in
containing the infection include:
1. Contact tracing by fully trained personnel.
2. Readily available, accessible and well-publicized clinics in
strategic positions dealing specifically with sexually transmitted
diseases.
3. Large-scale screening programmes of women. These
been remarkably successful in the USA in finding new cases and
reducing the infectious pool. They may be valuable in regions with
endemic-gonorrhoea but may have less scope elsewhere.
4. Health education: studies have shown a wide-spread ignor
ance amongst young people but also of young doctors due to lack of
teaching the subject.
5. Epidemiological treatment, especially of women and homo
sexual men. This proved valuable in our experience and is also the
policy in the USA.
6. Regular check-ups of high risk individuals.
Treatment There are differences in the type of antibiotics used,
the favoured mode of administration, and dosage schemes between
individual clinics in a country’ and even more markedly between
BReferences
countnes though the antibiotic sensitivity patterns are c imparable.
Csonka, G. W. and Knight, G. J. (1967). Therapeutic trial of trimethoprim
The results, however, appear to be similar. This suggests that a fair
as a potentiator of sulphonamides in gonorrhoea. Br. J. vener. Dis. 43,
4 degree of latitude is permissible in the treatment of gonorrhoea. k
Another factor which forces one to vary treatment is the ability of Hager, W. D. and Wiesner, P. J. (1977). Selected epidemioloeic aspects of
the versatile gonococcus to increase its resistance to a variety of ‘ . amt*
acute cainincnncsalpingitis: A
a reriew. J.
t reproducl. Med. io
19, .n
47.
Holmes, K. K.i Counts, G. W. and Beaty, H. N. (1971). Disseminated
unrelated compounds. The treatment suggested in Tables 1,2, and
. gonococcal infection. Ann. intern. Med. 74, 979.
3 is based on experiences at many centres but may need frequent
.. Jacobson, L. and Westrom, L. (1969). Objectivized diagnosis of acute
up-dating.
'■ "
pelvic inflammatory disease. Am. J. Obstet. Gynec. 105, 10S8.
Owen, R. L. and Hill, J. L. (1972). Rectal and pharyngeal gonorrhoea in
Follow-up examination. In the male with uncomplicated gonor
. homosexual men. J. Am. Med. Ass. 220, 1315.
rhoea. The patient is asked to return if the signs do not clear
Pariser, H., Farmer, A. D.. and Marino, A. F. (1964). Asymptomatic
/ promptly after treatment and at any time should they reappear.
ev
..w....w.........
gonorrhoea
in the. male. Southern r/4CU
med.. J. 57, uoo
6S8..
Otherwise he is examined one week after treatment for gonococcal
Thompson, S. E. (1981). The clinical manifestations of gonococcal infecand non-gonococcal urethritis. If at that time there is no evidence of ,:;r.; lions. In Recent advances in sexually transmitted diseases (ed. J. R. W.
gonorrhoea it is unlikely Jo return unless the patient is reinfected. If
Harris). Churchill Livingstone, Edinburgh.
there is PGU, this is treated. A final test which includes a second _. wiesner, P. J. and Thompson, S. E. (1979). Gonococcal diseases. In
blood test for syphilis is performed two months later.
Disease-a-month (ed. H. P. Dowling). Year Book Medical Publishers,
. In practice many patients default once the symptoms and signs
. nuaS°have disappeared.
In the female with urncomplicated gonorrhoea. Cure is indicated
• .
by two sets of negative cultures taken at weekly intervals after < Genital candidiasis
'
'
treatment and a final test including the second blood test for syphilis
two months later. If rectal gonorrhoea, was also found initially, J G. W. Csonka
rectal tultures should be repeated at every attendance as persis
Definition. Genital candidiasis (candidosis, moniliasis, thrush) is
tence of gonococci at this site may occur.
■ an infection usually due to Candida albicans causing vulvovaginitis
In patients of either sex with rectal or pharyngeal infection two . in women, balanitis or balanoposthitis in heterosexual men, and
negative cultures taken at weekly intervals, after treatment and a
anorectal infection in homosexual males.
second blood test for syphilis two months later are satisfactory.
Thus dn average patients with uncomplicated gonorrhoea need
Aetiology. Im98 per cent C. albicans is responsible, in the rest one
attend the hospital only three or four times.
of the other Candida species are isolated. The yeast grows as a
,
With high risk patients such as promiscuous homosexual males
non-capsulated oval blastophore which reproduces by budding. In
and female prostitutes the same routine is followed. Three-monthly
vivo and in culture, elongated thin hyphae may develop.
• check-ups are recommended.
Epidemiology. The
fungus vuu
can be
found aiijwji&ic
anywhere uiriuc
bn the iiumaii
human
I
• '
*■»* iuhjuj
uuwuiiu
’ Prognosis. At present all patients with uncomplicated gonorrhoea^- * body but most commonly in the mouth, nails, vagina, and anorectal
can be cured. If they fail on one antibiotic an effective alternative
canal. C. albicans is an opportunist and exists often as a saprophyte
can be found. Routine screening for
for/Llactamase-producing
/Mactamase-producing organ--, becoming pathogenic under certain host conditions which include
i c' rwc*
1I
r 1 irA tnot notl Ante in
kat zxf*
.C
.
' x'
* J_
isms will
ensure
that patients infected with such r*strains will receive ■ : rvrartn
pregnancy^ diabetes,
administration of
antibiotics,corticosteroids//
the appropriate treatment at the earliest opportu iity. Non-; ■■ and possibly oral contraceptives.' The wearing of nylon pantihose
gOfiocOecal ififsetiGfiS associated With gonorrhoea may cause prob-creates a mbistt worm'environment which encourages funartl
rums.
tWhiids responds to tetracycline as readily • growth.Tn a proportion of women none of these factors is found,
as NGU alone but there have been no large-scale studies comparing
It is apparent that in many female patients; genital candidiasis is
' recurrence rates or those of complications between PGU and . , not sexually initiated though it may. subsequently be transmitted
NGU. Reiter’s disease can follow PGU.
. . sexually to the male partner. In menj sexual transmission is .the
The prognosis in complicated gononhoea is good except in the : . rule./‘. j.-Jf??/ :. r’if.;?
■ •-. • . ..
. "■
case of pelvic; inflammatory disease -and the rare gonococcal
Prevalence. The infection is worldwide and appears to be increase
THE NEW
OUR BODIES,
OURSELVES
a~rook~by and for women
The Boston Women’s
Health Book Collective
V.caUt As:-cciat;Oc^\
. 0/
VHAI I_U-*AR-
V
* i
«x>
>
, S:- -
A TOUCHSTONE BOOK
PUBLISHED BY SIMON & SCHUSTER, INC.
New York
CONTROLLING OUR FERTILITY
Changes We Can Make Now
Although some medical professionals maintain that
jiuuv*. for our current STD epidemic is to
the only solution
-luu
a
develop a ipreventive vaccine, others believe that we
can and should attempt to contain the diseases now.
1V is possible, to reverse the trend toward an in
It
creased, incidence of gonorrhea. Several European
countries and China have done so by educating the
people about prevention, symptoms, testing and treat’
P V Sweden, by promoting the condom, has reduced
ment. Sw<
incidence of STDs without restricting sexual ac
the i.----tivity.
tivity.
, __ ,
v.„„„
we need to
In order to use the tooh we have now, we
lhe aUimde'dtaTsTD is a punishment for “imchange
raj" sex. We must demand and initiate public ed
m<
uc ition programs without moral overtones in our
ools and communities. There are some nonjudgscHooi
!ntal films, pamphlets and brochures (see Reme
irces), though few deal with Preventive measures
SOI
can use. We can distribute them in public places
wqmen
th as libraries, schools, movie houses, social centers
: su
d health facilities; we can talk with friends, parents
d chiidren to make sure they have as much accura e
and
>rmaiion a.
information
as possible.V.c
Wecan support women s cenk as they work for more complete sex and health
tejskcation.
sexuality it will
education, When
wnen our
uui society accepts
---------be more likely to en5ourage £TD^e/^^riQilif_t^(;;t.
Pracritioners must learn more about STDs. Self-test
ink kits have been developed and should be made
-’hilable. More
More paramedics
lay
aVaiiaDie.
paruiucuivs and —
j health
-------- workers
-----should be involved in running community screening
programs to make tests, screening and treatment
available to all economic and social groups. We can
ask for routine screening tests for STD when we go for
medical care; medical workers will be more^ apt to
[elude tests automatically if a large number of clients
ri quest them.
SEXUALLY TRANSMITTED
DISEASES: SYMPTOMS AND
TREATMENT*
Gonorrhea
donorrhea is caused by the gonococcus, a bacterium
shaped like a coffee bean, which works its way grad
ually along the warm, moist passageways of the gen
ital and urinary organs and affects the cervix, urethra,
anus and throat. You can transmit this disease to an
other person through genital, genital-oral and genital*For more information about tests, drugs and how STDs affect
men than we can include in this chapter, see 'A Book ANjui Sex
ually Transmitted Diseases," listed in Resources under Booklets,
Pamphlets and Reprints.
rectal sex. You can get a gonorrhea infection in your
eye when you touch it with a hand that is moist with
infected discharge. A mother can pass it to her baby
during birth. Occasionally very young children can
contract gonorrhea by using towels contaminated with
fresh discharge. More frequently, children with gon
orrhea are found to have been sexually abused Evi
dence of gonorrhea has also been found in donor semen
used for artificial insemination.10
The disease is more likely to persist and spread in
women than in men. Untreated gonorrhea can lead to
serious and painful infection of the pelvic area called
pelvic inflammatory disease (PID). S«venteen.p®r“"t
of the women known to have gonorrhea develop PI ,
of these, 15 to 40 percent become sterile after just one
CPA less common complication is proctitis tnflarnmation of the rectum. If the eyes become infected by
gonococcal discharge (gonococcal conjunctivitis),
blindness can result. Disseminated gonococcal infec
tion, rare but serious, occurs when bacteria travd
through the bloodstream, causing infection of the heart
valves or arthritic meningitis. Gonorrhea can be treated
at any stage to prevent further damage, but damage
already done usually cannot be repaired.
Remember, it is important to use Prevent^e measV ••a :woman
---does not have early- e symplures, since
—— » -often
g.—- ------toms. By the time pain prompts her to see a doctor,
the infection has usually spread considerably. A woman
- can be
who has had -a hysterectomy
t. infected in the
ixGf
cervix
(if it is left), the anus, urethra or throat.
Symptoms
Although women often have gonorrhea without any
symptoms, as manyy as
as 40 to 60 percent don't notice
mildness, or confute
symptoms because of
c. their
—
, them
with otnerconamuiAA.
other conditions. Symptoms usually appear
with
• i any
where from two days to three weeks after exposure.
exposure^
The cervix is the most common site of infection. In
cervical gonorrhea, a discharge develops which is
caused by an irriunt released by the gonococci when
they die. If you examine yourself with a specu urn you
may see a thick discharge, redness and small bumps
or signs of erosion on the tervix. You may at first
routine -gynecological
attribute symptoms to other
<—~ of
~ L2--*“'‘bods like
problems or to the use
birth control’ metho'
infected,_POS"
the Pill. The urethra may also become infectei
sibly causing painful urination and burning. As the
infection spreads, it can affect the Skene’s (on each
) --------and Bartholin^, glands.
side of the urinary opening)
Vaginal discharge and anal intercourse can infect the
rectum. Symptoms include anal irritation, discharge
recium
y y
and painful
bowel movements. If
If the
the disease^
disease spreads
s
to the uterus and fallopian tubes, you may ha'ive pain
on one or both sides of your lower abdomen, vo•miting,
fever and/or irregular menstrual penods. Th.ie more
severe the infection, the more severe the pain and other
268
SEXUALLY TRANSMITTED DISEASES
—eyes
pharynx
painful joints and
tendons (DGI)
-fallopian tubes
(salpingitis)
-uterus
cervix
urethra, glands, bladder
rectum
GONORRHEA
Christine Bondante
Don’t douche right before a test, because you can
wash away the accessible bacteria, giving a false neg
ative test result. The gram stain and the culture are
two standard tests for gonorrhea in current use. A
woman can have them done during a pelvic exami
nation or a throat exam. The widely used gram stain
is very accurate for symptomatic men J^ut only 50 per
cent accurate for women and asymptomatic men. Ir
this test a smear of the discharge is placed on a slid,
stained with a dye and examined for gonorrhea bat
teria under a microscope. If jour regular male part
ner’s test is positive, you may want to be treated at
the same time regardless of the test results.
The culture test (more reliable, but it takes longer)
involves taking a swab of the discharge, rolling it onto
a special culture plate and incubating it under special
laboratory conditions for sixteen to forty-eight hours
to let the gonorrhea bacteria multiply. Even the cul
ture test can be inaccurate, primarily because it is
difficult to maintain specimens in good condition dur
ing transportation to the lab. Test accuracy also de
pends greatly on which sites are chosen for testing. If
you have the most commonly affected sites (cervix and
anal canal) cultured, there is about a 90 percent chance
of finding any existing infection. (Many women with
gonorrhea also have trichomoniasis and/or chlamy
dia.) The swab from the cervix is the best single test,
about 88 to 93 percent accurate. About 50 percent of
women with infected cervices also have infection in
the anal canal. If you have had a hysterectomy, ask
for a urethral culture, too. If you have had oral-genital
sex, ask for a gonococcal throat culture. Ask what kind
symptoms are likely to be. These symptoms may in
dicate PID.
Gonorrhea can also be spread from a man s penis to
a woman’s throat (pharyngeal gonorrhea). You may
have no symptoms, or your throat may be sore or your
glands swollen.
One to 3 percent of women with gonorrhea develop
’disseminated gonococcal infection (DGI). Symptoms
of DGI include a rash, chills, fever, pain in the joints
and tendons of wrists and fingers. As the disease pro
gresses, you may have sores on the hands, fingers, feet
and toes.
Men's Symptoms
A man will usually have a thick milky discharge
from his penis and feel pain or burning when he uri
nates. Some men have no symptoms. Gonorrhea in a
man is often confused with nongonococcal urethntis
(NGU), which also produces a discharge and requires
a different drug for cure. If you have had sex with a
man who has a discharge from his penis, get him to
go for a test right away. His discharge can be tested
and diagnosed the same day. If he does not have gon
orrhea or NGU, then you will not have to take unnec
essary medication.
Testing and Diagnosis
It is important to be tested before taking medication,
because a test done while treatment is being given is
not accurate.
269
CONTROLLING OUR FERTILITY
reasons: tests are not always accurate; the physician
is not sure you will come back; and the sooner the
gonorrhea is treated, the easier it is to cure. Ask about
medication for your partner.
On the other hand, some places refuse to treat you,
even when you are certain of infection, until a positive
• _ is
•_____
1_ One argument i«-»
itincr
diagnosis
made.
in favor nF
of ws
wilting
for test results is that you should not take antibiotics
__________
'
“
’l gon
unnecessarily.
Also, NGU, often
confused
with
orrhea, is treated with tetracycline rather than peni
cillin, so it is important to know which infection you
have. If you are not sure which you have been exposed
to and don’t want to wait for the results of the cu ture,
ask to be treated with tetracycline, effective for both
gonorrhea and NGU. If you decide to wait for ths cul
ture test results, you must consider whether or not it
will be easy for you to return for possible later tests
and treatment.
An IUD may make cure more difficult since it helps
spread infection and increases the chances of getting
PID. Have your IUD removed before treatment.
High-dosage injections of penicillin or high oral doses
of ampicillin or amoxicillin are the usual treatments
also
cu|e syfor gonorrhea. Injected penicillin can j
1 ------philis still in the incubation stage. You may also receive oral probenecid, a drug which slows down the
urinary excretion of antibiotics and allows them to
remain in the bloodstream in high enough concentra
tions to do the job.
Some doctors recommend tetracycline as a treatment of choice because it avoids the risk of serious
side effects of allergy to penicillin. Its disadvantage is
that you must take it regularly for two weeks or so for
it to be effective. Tetracycline also has a high failure
rate in cases of anal and rectal gonorrhea. For more
information on these drugs and possible undesirable
effects (such as yeast infections), see “Drugs Women
Should Know About* and “A Book About Sexually
Transmitted Diseases,’ listed in Resources.*
Over the past twenty-five years, gonorrhea has required increasing doses of penicillin to cure, and new
new
strains of gonorrhea have emerged which are res stant
to the drug. In 1972, 22 percent of the strains of gon
orrhea were resistant to penicillin. That number has
now dropped to 4 percent. One strain, penicillinase
producing N. gonorrhea (PPNG), remains high y dif
ficult to treat. Soldiers stationed in the Fat East
brought it back with them to the U.S.t In this case,
the gonococcal organism produces an enzyme (peni
cillinase) that destroys penicillin, making the drug.
of medium is used for culturing. Thayer-Martin or
Tra isgrow are best.
Often women will have both tests, the gram smear
5 test t0 c0^rTn
______ screening
_____
for [initial
and the culture
the "diagnosis. If the smear is negative but you have
definitely
been exposed to gonorrhea, you may want
m^uT^aywhntTwaitingfbrthe^esuiuLf
the culture to cOme back.
Elven though these tests are not completely reliable,
in physicians^
physicians’ ofof
they are the most widely available m
fices and clinics. If you have any doubts,as to how
acc urate the results of your test were, try to have some
one else do one or come back again within a week or
two, the sooner the better.
Other Tests
•
The FDA has recently licensed two new tests for gonorrhea. The Eliza technique (trade name Gonozyme)
detects antigens to the gonorrhea bacteria in cervical,
anal or urethral specimens. This test can be performed
in pne or two hours, but'the technology is more com
plicated and much more expensive than that of the
culture test. Currently, medical practitioners still pre
fer the culture test when they have a good laboratory
nearby to do if5
The second test, the Gonosticon Dri-Dot test, is cheap
enough (about one dollar) for office use, but it is not
yet widely available. The test involves examining a
patient’s blood for antibodies to gonorrhea. According
to he Center for Disease Control, which does not rec
ommend the test, there are two problems with this
pncedure: one is that a blood test cannot detect a
recent infection because antibodies take time to build
up in your system; another is that if antibodies from
a previous
pjrevious infection are present, the test may give false
results. Some doctors, however, recommend the test
onThe
on the basis that it may be useful for diagnosing women
who have abdominal PID or arthritis as a result of
gonorrhea.
Another test, not yet approved, is the Transformation
test
tes (also called the C Test). It detects infection in a
cervical specimen by isolating DNA from gonorrhea
bacteria. Research is being done to see if this method
could be adapted for use in a self-test kit, perhaps
using a tampon to collect specimens. No field trials
have been conducted to date. So far, it is cheaper and
simpler but not quite as accurate as the culture test.
A monoclonal antibody test, also not yet approved,
* i one
shiws great promise for diagnosing gonorrhea in
two
’
hours.
For
this,
a
smear
of
the
infected
area
to
is exposed to mouse antibodies and is examined
under a fluorescent microscope for evidence of the
bacteria.” “
‘Those of African and Mediterranean ancestry should check for
should
sensitivity to sulfa drugs and probenecid. Pregnant women s.
-----not take tetracycline.
tOutbreaks of STD have always been clearly related to war
zones, where normal life is disrupted, where women are raped or
forced to earn a living through prostitution and where n^edicine
is available only through a black market.
Ti^eatment
Many physicians prescribe medication before the
cu ture test is back or diagnosis is certain for three
270
SEXUALLY TRANSMITTED DISEASES
toms of infection. While ureaplasma causes up to onequarter of the cases of NGU in men,* it is not generally
thought to cause cervicitis or PID in women.! How
ever, some researchers believe it can cause other gen
ital tract infections and pregnancy complications (see
below).!’2
useless for treatment. Tetracycline is also ineffective.
If a culture indicates PPNG, other medications such
as spectinomycin, cefoxitin and cephalosporin will be
prescribed.
Test for Cure
Every woman treated for gonorrhea should have two
negative culture tests, including a rectal culture, a
week or two apart before considering herself cured. If
cultures remain positive, get retreatment with another
antibiotic such as spectinomycin and a culture tor
PPNG. Pockets of infection in reproductive organs may
be difficult to cure. If your partner has gonorrhea, you
can become reinfected very soon after a cure, so it s
crucial that he be tested and treated as well.
Symptoms
Women often don’t know they have these infections.
The cervix may or may not appear inflamed upon ex
amination. If you have no symptoms, you must rely
on your partner to tell you if he has symptoms or has
been diagnosed for NGU. Women who do have symp
toms may experience dysuria (painful unnation), cys
titis, a thin vaginal discharge and/or lower abdominal
pain ten to twenty days after exposure.
Gonorrhea and Pregnancy
Pregnant women should receive at least one routine
gonorrhea culture during pregnancy A pregnant
woman with untreated gonorrhea can infect her baby
as it passes through her birth canal. In the past, many
babies went blind due to gonococcal conjunctivitis.
All states now require the eyes of newborns to be treated
with silver nitrate or other antibiotic drops m order
to prevent this disease, even when the mother is sure
she does not have gonorrhea and knows the treatment
is unnecessary.
fallopian rubes (chlamydial PIDL
I
. cervix
(chlamydia)
urethra
uterus
(chlamydial PID;
Chlamydia
rectum
Until recently, the bacterium Chlamydia trachomatis
was thought to affect only men, causing; ha of the
cases of male nongonococcal urethritis (NGU), while
women were silent “carriers.” Now we know that chla
mydia can cause very serious problems for women,
including urethral infection, cervicitis (inflammation
of the cervix), PID and infertility as well as dangerous
complications during pregnancy and b*rth. (See be
low ) It has been linked to some cases of Reiter s syn
drome (an arthritic condition) and cervical dysplasia
(precancerous changes in cervical cells). If you practice anal sex, this organism can cause proctitis (in
flammation of the rectum).
Chlamydia is transmitted during vaginal or anal sex
with someone who has the infection. It can also be
passed by a hand moistened with infected secretions
to the eye, and from mother to baby during delivery.
CHLAMYDIA AND UREAPLASMA
Chlamydia can also be transmitted to the eyes via the
hands.
Christine Bondante
Men fs Symptoms
Men will usually have a burning sensation upon ur
ination and a urethral discharge that appears one to
three weeks after exposure. Symptoms may be similar
to those of gonorrhea, but are usually milder .’The in
cubation period is also generally longer—at least seven
days. About ten percent of men have no symptoms,
even though they can still transmit the disease. Fre-
Ureaplasma
cent by iTeaplasma and 25 percent by as yet unidentified orga
nisms.
tSome researchers dispute this assumption.
If your partner has NGU, you can also become infected
by Ureaplasma urealyticum (also called T-Alycoplasmd), transmitted separately from or together with
chlamydia. It has been found in the genital tracts of
many apparently healthy people who have no symp-
causJSeTti^nsTeading to PID and, according to some research
ers. infertility and/or premature birth.
271
CONTROLLING OUR FERTILITY
are pregnant. The blood tests presently available for
chlamydia are currently considered too impractical
for widespread use.
quently only one member of a couple will have symp
toms, while the other carries the infection. Both
partners must be treated to prevent passing the dis
ease back and forth.
Many practitioners are not yet aware of the dangers
of chlamydia. In addition, because chlamydial infec
tion is so easy to confuse with gonorrhea and other
diseases, they often misdiagnose it. They also overlook
women’s symptoms or attribute them to other causes.
New Tests
The FDA recently approved a monoclonal antibody
test for chlamydia that the manufacturer reports is 92
to 98 percent effective and gives results in less thar
an hour. The test uses a cervical smear. It should b
come widely available in 1984 and be much less ex
pensive than the culture test. If the test performs as
expected it is likely to replace the culture test in a few
years (see p. 274).
It started out as cystitis. A few months later I started
having fever, chills and a lot of pain in my lower ab
domen. The doctor never said anything about the pos
sibility of chlamydia or PID. Instead they did tests for
gonorrhea, which were negative. After six months of be
ing really sick, they gave me ampicillin, which didn't help.
They kept saying, “There's nothing wrong with you. You
must be having emotional problems.’' After nine months
1 had a good case of PID, which they called “a little
pelvic infection.” It wasn’t until my husband came down
with symptoms of NGU that they took me seriously and
treated us both with the right drugs.
.
Treatment
Tetracycline is the standard treatment for chlamy
dia and ureaplasma infections. Doxycycline and min
ocycline, also prescribed, are much more expensive
and can cause serious negative side effects. Ery
thromycin is often prescribed when tetracycline can
not be given. Sulfa drugs such as sulfamethoxazole
trimethoprim (Septram, Bactrim) are effective against
chlamydia but not ureaplasma. Many of the other an
tibiotics commonly used for STD infections, including
penicillin, are not effective. People with chlamydial
eye infections are treated with local antibacterial
agents such as chlortetracycline.
Take all the medication prescribed, or the infection
may come back at a later date, cause more trouble
and be harder to get rid of. Usually it clears up within
three weeks. If not, go back to the practitioner, who
will prescribe a different antibiotic or a longer treat
ment time. Regular sexual partners should take tetra
cycline whether or not they have symptoms. Because
10 percent of ureaplasma is resistant to tetracycline,
some practitioners recommend a follow-up culture one
to four weeks after treatment.
Before taking any antibiotics, check with your doc
tor about possible undesirable effects.* Pregnant
women should not take tetracycline. Avoid alcohol un
til the infection is cured, as it may irritate the urethra.
Use condoms until you and your partner are cured. If
you seem to keep having recurrent episodes of chla
mydia or MPC and antibiotics have not cleared up the
infection, you may have another bacterial infection or
possibly a stubborn case of PID.
Remember, the usual treatment for gonorrhea is not
effective against these organisms. If you think you have
been exposed-to NGU, wait for the results of a test
before accepting treatment for gonorrhea. If you can’t
wait or don’t want to come back, make sure to be
treated with tetracycline, effective against both gon
orrhea and these organisms.
Testing and Diagnosis
At present there is no widely available test specifi
cally for chlamydia or ureaplasma. Sometimes a skilled
lab technician can diagnose chlamydia by a Pap smear,
la most cases, if you or your partner has a discharge,
u will be tested for gonorrhea, and if that is negative,
iji.4 practitioner will diagnose NGU/MPC by elimina
tion. Incubation of the disease is also a clue. NGU takes
ionger to show up than gonorrhea, although the time
period can vary, depending on whether chlamydia,
mycoplasma, a combination of the two, or other bac
teria are causing the infection. Some experts think
that when a man suspects he may have NGU, he should
have his seminal fluid (obtained by masturbation)
checked.13 The CDC, however, maintains that a ure
thral smear is the only accurate test. Tests for chla
mydia and ureaplasma involve taking a swab from the
cervix and culturing the specimen, and are performed
only at large medical centers and some public health
laboratories. For information on where to get tested,
call your public health department. Unfortunately,
these cultures are expensive (thirty-five to forty dol
lars). For these reasons, many physicians are reluctant
to recommend them. Some prefer to wait until a wo
man’s partner develops symptoms of NGU. This trend
may be slowly changing, particularly when women
Chlamydia, Ureaplasma and Pregnancy
Recent studies indicate that 8 to 10 percent of all
pregnant women may be infected with chlamydia14
which, if untreated,can then be transmitted to the baby
during birth. Infected babies may develop conjunctiv*See note, p. 270, regarding sensitivity to some of these drugs.
272
SEXUALLY TRANSMITTED DISEASES
itis or pneumonia. Chlamydia has also been linked to
miscarriage, ectopic pregnancy, premature delivery and
postpartum infections. Because of these risks, testing
for chlamydia may soon be recommended for all preg
nant women.
Because ureaplasma has also been strongly impli
cated as a cause of infertility, miscarriage and pre
mature birth, some researchers feel that any woman
with a history of infertility or ectopic pregnancies
should be tested for ureaplasma as well.15
gers. It can also be spread through linens and towds
although this happens rarely. Although the disease is
normally contagious only from the time the skin red
dens until the sores crust over, herpes can possibly be
transmitted when no symptoms are present., but t; ;
chances of this happening are minuscule.
Symptoms
Symptoms usually occur two to twenty days after a
primary exposure, although some people may^ot have
symptoms or may not be aware of them until m> ch
later. An outbreak of herpes usually begins with a Lr
gling or itching sensation of the skin in the genital
area. This is called the “prodromal" period am’ may
occur several hours to several days before the sore >
erupt, or it may not occur at all. You may also expe
rience burning sensations, pains in your legs, buttocks
or genitals and/or a feeling of pressure in the area.
Sores then appear, starting as one or more red bumps
and changing to watery blisters within a day or two.
Blisters are most likely to occur on the labia majora
and minora, clitoris, vaginal opening, perineum and
occasionally on the vaginal wall, buttocks, thighs, anus
and navel. Women can also have sores on their cervix,
which usually cause no discernable symptoms. Ninety
percent of women have sores on both vagina and cer
vix during a first infection. Within a few days, the
blisters rupture, leaving shallow ulcers which may
ooze, weep or bleed. Usually after three or four days
a scab forms and the sores heal themselves without
treatment.
Herpes
Herpes (from the Greek word “to creep*) is caused by
the herpes simplex virus, a tiny primitive organism
whose nature is still more or less a mystery. The virus
enters the body through the skin and mucous mem
branes of the mouth and genitals, and travels along
the nerve endings to the base of the spine, where it
sets up permanent residence, feeding off nutrients pro
duced by the body cells. There are two types of herpes
simplex (HSV) viruses. Type I (HSV I) usually is char
acterized by cold sores or fever blisters on the lips,
face and mouth, while Type II (HSV II) most often
involves sores in the genital area. While HSV I is usu
ally found above the waist and HSV II below, there is
some crossover, primarily due to the increase in oral
genital sex. In this chapter we will be concerned with
genital herpes.
You can get herpes during vaginal, anal or oral sex
with someone who has an active infection. You can
spread it from mouth to genitals (or eyes) via the fin-
headache and fever,
(first outbreak)
eyes (transmitted via hands)
r.L
lips and mouth (usually associated with HSV I)
I
navel
vagina
cervix
7
painful lymph nodes in groin
genital area (clitoris, labia,
vulva, jhighs, perineum,
^buttocks)
o
GENITAL HERPES
273
.41
Christine Bondanie
CONTROLLING OUR FERTILITY
evaluation. A fairly accurate method of diagnosis, it
can be used for both men and women, and is inexpensive (three to fifteen dollars). It cannot differen
tiate between HSV I and HSV II.
vyhile the sores are active, you may find it painful
to Urinate, and you may have a dull ache or a sharp
burning pain in your entire genital area. Sometimes
the pain radiates into the legs. You may also have an
urgp to urinate frequently and/or a vaginal discharge.
You may also have vulvitis (a painful inflammation
of the vulva). During the first outbreak, you may also
experience fever, headache and swelling of the lymph
nocjes jn the groin. The initial outbreak fc usually the
moit painful and takes the longest time to heal (two
to six weeks).
Viral Culture
A viral tissue culture can be taken using living celis
to grow the virus. This test has an advantage in that
it can distinguish between Herpes I and Herpes If, but
it is expensive (about forty-five dollars) and few laboratories or doctors are equipped to perform 't
it The
test is more accurate than the smear and shou d be
done when the sores first appear.
Men's Symptoms
L” ■
Other Tests
Men may experience pain in the testicles during the
prodromal period, followed by sores which usually
appear on the head and shaft of the penis but can also
appear on the scrotum, perineum, buttocks, anus and
thighs. Men can also have sores without knowing it,
usi^ally because they are hidden inside the urethra.
There may also be a watery discharge from the ur-
You can get a blood test to measure the level of
herpes antibodies in the blood. (Once you have been
exposed to the virus, your body manufactures> antibodies to fight off the infection.) For this test two
ampules of blood are drawn, one during the initial
attack and the second two to four weeks later. If you
have herpes, the second sample will show a much
higher antibody level. (It takes about two weeks to
build antibodies.) This test is only effective when per
formed during the initial attack of herpes. Later, the
test results are difficult to interpret. This test costs
thirty-five to fifty dollars and may not be covered by
all federal or state medical assistance programs. Some
public health departments in metropolitan areas,
however, provide the test free of charge.
A monoclonal antibody test is being investigated now
to determine how accurate it is. It still cannot detect
latent cases (see p. 272).
• ethfa.
Recurrences
Some people never experience a second outbreak of
hertpes, but most people (75 percent) do, usually within
thrbe to twelve months of the initial episode and usu
ally in the same area of the body. Recurrent episodes
are usually milder, last from three days to two weeks
and usually do not involve the cervix. They often seem
to be triggered by stress, illness, menstruation or preg
nancy. Most people find that the number of yearly
recurrences decreases with time. Because recurrent
heijpes is associated with lowered resistance, some
people believe the infection can lead to secondary in
fections such as trichomoniasis, bladder infections, ve
nereal warts, yeast infections and vaginitis. Poor diet
and drugs that weaken the immune system (such as
caffeine, speed, birth control pills and diet pills) may
also make you more susceptible to recurrences. People
who are deficient in B-vitamins or who are unusually
tense seem to get more frequent recurrences. Recent
studies show that HSV II is much more likely to recur
than HSV I"
Treatment
At present there is no medical cure for herpes, alvaccines, anti
though researchers are investigating
v
viral therapy and immune-system stimulants.* In the
meantime, keep sores clean and dry. If they are very
painful, you may want to get a prescription for xylocaine cream or ethyl chloride. If you are having an
outbreak of genital herpes for the first time, your prac
titioner may prescribe a new antiviral drug called acy
clovir (trade name Zovirax). Acyclovir seems to reduce
pain and viral shedding (the period during which the
virus is infective) but it does not delay or prevent re
currences and it won’t help if you already have the
disease. Acyclovir in oral form may prevent recur
rences, according to one study, and should be ap
proved for use by the FDA in 1984.17 It is still not
considered a cure, however.
Testing and Diagnosis
You and your practitioner can usually diagnose
herpes by sight when the sores are present, although
herpes is occasionally confused with chancroid, syphi
lis or venereal warts. Several lab tests confirm the
diagnosis or indicate the presence of herpes even when
no sores are active.
•In the past few years more than thirty experimental treat
ments for herpes have been tested and found ineffective in clin
ical trials. For a list of these experimental treatments, some of
which are still used, and other information, send for “Questions
and Answers on Genital Herpes,’ Technical Information Ser
vices, Division of Sexually Transmitted Diseases, CDC, Atlanta,
GA 30333. Il is free.
The Tzanck Test
This test is similar to a Pap smear. A scraping is
taken from the edge of an active sore, smeared on a
slide sprayed with a cell fixative and sent to a lab for
274
SEXUALLY TRANSMITTED DISEASES
7. Acupuncture treatments administered at the first
signs of an attack sometimes prevent recurrences. Fin
gertip stimulation of acupressure points in the feet
may also prevent outbreaks (three thumbs forward of
the ankle bulge, along the line between the ankle bulge
and little toe).
Another promising experimental treatment involves
the use of laser beams which, when applied to sores
within forty-eight hours of a first outbreak, may help
prevent recurrences. This method also seems ineffec
tive for women who already have recurrent herpes.18
Self-Help and Alternative Treatment
For Symptomatic Relief
When sores first appear, take warm sitz baths with
baking soda three to five times a day. In between, keep
sores clean and dry. A hair dryer helps to dry sores.
Sores heal faster when exposed to air, so wear cotton
underpants or none at all. If it hurts to urinate, do it
in the shower or bathtub or spray water over genitals
while urinating (using any plastic squeeze bottle).
When sores break, apply drying agents such as hydro
gen peroxide or Dom Burrows, which is available in
drugstores. For pain relief, take acetaminophen (e.g.,
Tylenol) or aspirin.
Many women have found the following alternative
treatments very helpful for herpes.* They may or may
not work for you. Because some of the products men
tioned below must be purchased at a health food store,
they may be expensive. We suggest that you pick one
or two. Remember, all are most effective when com
bined with good nutrition and rest. (If you are preg
nant, don’t take medicinal teas or high doses of Vitamin
C without consulting your practitioner.)
1. Echinacea is a blood-purifying plant. Capsules
made from it are available at health food stores. Take
two capsules every three hours, make a tincture and
apply (one teaspoon every two hours for three to four
days) or make a soothing tea (four cups a day).
2. Take 2,000 milligrams of Vitamin C or two cap
sules of kelp followed by sarsaparilla tea (four to five
cups during the day).
3. Chlorophyll (in powder form) and wheatgrass are
good antiviral herbs. Drink them with warm water.
Also, eating blue-green algae (3,000 milligrams daily)
may be helpful.
4. Lysine is an amino acid that many women find
very effective in suppressing early symptoms. If you
stop using it, symptoms may reappear. Take 750 to
1,000 milligrams a day until sores have disappeared.
Thereafter take 500 milligrams a day. Lysine seems to
work by counteracting the effects of argenine (a sub
stance found in foods such as nuts—especially pea
nuts—chocolate and cola) which stimulates herpes.
During any herpes episode it is wise to avoid argeninerich foods.
5. Zinc: take five to sixty milligrams daily.
6. Grape skins may be antiviral. Some women rec
ommend eating red grapes.
1. Make compresses out of tea made with cloves, use
black tea bags soaked in water (tannic acid is an an
esthetic) or take sitz baths with uva-ursi (also known
as kinnikinnjck or bearberry).
2. Apply peppermint or clove oil. Vitamin E oil, A
and D Ointment, baking soda, cornstarch or witch ha
zel to the sores. (Some people believe that keeping the
sores moist may make them feel better but last longer.)
Before applying any salve, some people suggest you
rub the area with mouthwash containing thymol.
3. Make poultices using pulverized calcium tablets,
powdered slippery elm, goldenseal, myrrh, comfrey
root or cold milk. Make a paste using any of these and
apply to the sores. After applying, keep the paste mois
tened with warm water.
4. Aloe vera gel soothes and helps to dry out sores
and promote healing.
Herpes and Pregnancy
Studies show that women with herpes have an in
creased risk of miscarriage and premature delivery.
Equally important, when a mother has^ctive sores at
the time of delivery, herpes can be transmitted to the
baby during passage through the birth canal, causing
brain damage, blindness and death in 60 to 70 percent
of cases. Scary as this sounds, jt is important to know
that this is rare, occurring only in one out of every
7,000 normal births. The risk is much higher when
mothers have a primary outbreak at the time of de
livery; when they have open sores, their babies have
a 50 percent chance of contracting herpes during a
vaginal birth. For a mother with recurrent sores, the
risk goes down to about 4 percent because she has
passed antibodies on to the baby through the amniotic
fluid and the baby’s blood.19
Pregnant women who don’t have herpes should avoid
unprotected sex during the last six weeks with part
ners who have herpes. If you are pregnant and’have
recurrent herpes, get a Pap smear or viral culture done
regularly from thirty-two weeks of pregnancy to de
livery. If you have prodromal symptoms or active
sores at the time of delivery, you will usually have a
Cesarean section within four to six hours of the time
the waters break. Some studies suggest that women
who have negative cultures within three days of birth
can and should deliver vaginally. After birth, take care
not to infect the infant. After about three weeks, babies
usually do not develop serious infections.
♦Information adapted from "Herpes." Santa Cruz Women s
Health Center; "Her Pease," Women's Health Sen ices, Santa Fe.
NM; and "Herpes, Something Can Be Done About It, by N.
Sampsidis. To order copies of these booklets, see Resources.
275
CONTROLLING OUR FERTILITY
2. Limit the use of stimulants such as coffee, tea,
colas and chocolate.
3. Increase your intake of Vitamins A, B, C and pan*
tothenic acid as well as zinc, iron and calcium to help
prevent recurrences.20
4. Avoid foods which have a lot of argenine (such as
nuts, chocolate, cola, rice and cottonseed meal)?' In
stead, eat foods high in lysine: potatoes, meats, milk,
brewers' yeast, fish, liver and eggs.
Cytomegalovirus (CMV), another virus related to
heroes which may be an STD, seldom causes symp
toms in the mother but is also thought to be a major
cause of birth defects.
Herpes and Cancer
Studies show .that women with genital herpes have
a five times' greater risk than others of getting cervical
cancer. This does not mean that just because you have
herpes you will get cancer, but it is advisable to get a
Pap smear every six months. It is possible that the
factors that make us susceptible to herpes are similar
to those which make us susceptible to cancer.
Living with Herpes
Accepting herpes as a permanent part of your life
may be difficult. You may feel shocked when you dis
cover you have herpes, and then frantically search for
a cure. You may feel isolated, lonely and angry, es
pecially toward the person who gave you the infection.
You may become anxious about staying in long-term
relationships, having children or getting cervical can
cer. Not everybody experiences herpes in these ways,
nor do these responses necessarily last forever.
Prevention
A herpes vaccine is being tested on people now, but
it ^ivill be at least 1986 and probably later before we
knpw how effective it will be. Only then will the FDA
approve it for general use. Because there is no cure
for herpes, it seems especially worthwhile to protect
yourself from getting it. That does not mean that you
should never have sex with someone who has the virus
in a latent stage; it simply means using your common
sense in evaluating the risk and taking simple precau
tions when possible. The following suggestions (along
with the general methods outlined on p. 266) may also
reduce your chances of getting herpes.
1. You will be less susceptible to herpes when you
are in good health, eating well and have ways of deal
ing with stress in your life (such as yoga, deep breath
ing, meditation—whatever works for you).
2. Avoid sex with someone who has active sores. If
you decide to go ahead anyway and your partner is
male, use condoms and/or a diaphragm with sper
micide containing Nonoxynol 9, which may possibly
be effective against the herpes virus.
3. Because herpes can be spread by skin contact from
one part of the body to another, try to avoid touching
an open sore. Wash your hands after examining your
self or touching the genital area. Always wash your
hands before inserting contact lenses.
After the first big episode of herpes, I felt distant from
my body. When we began lovemaking again, I had a hard
time having orgasms or trusting the rhythm of my re- .
sponses. I shed some tears over that. I felt my body had
been invaded. My body feels riddled with it; I'm somehow
contaminated. And there is always that lingering anxiety:
is my baby okay? It's unjust that the birth of my child
may be affected.
If you are in a close relationship with someone who
doesn’t have herpes, it can affect you both in subtle
ways.
Sometimes it bullies both of us. When my lover feels
she has to protect me from stress because I'm about to
get herpes, she doesn't always ask for attention, time or
comfort when she needs them.
How much herpes affects your relationships can de
pend a lot on how much you trust each other and how
comfortable you feel about sharing your concerns.
Protecting Others (If You Have Herpes)
My lover really trusts me when I say the episode has
passed and it's okay to have oral sex. She doesn't secondguess me and say, “Let's wait a few days so I wont get
it," What a blessing.
IL If you have active sores, you might try to keep
towels separate and wear cotton underpants in bed at
night, since herpes may be transmitted through shared
towels or linen.
2. Do not donate blood during an initial outbreak.
3;. Some people recommend avoiding swimming
po<|>Is, hot tubs and saunas during an initial outbreak.
Preventing Recurrences
The way we experience herpes may have a lot to do
with our attitude about disease. For example, people
who see herpes as a symptom of stress, illness or other
problems rather than as a medical disaster seem to
have a much easier time finding their own ways of
coping with it.
1. Herpes attacks seem to be triggered by stress. If
possible, figure out what precipitated your attacks and
try to eliminate or reduce tension in your life.
Herpes is an inconvenience and a pain, but it's some
thing you learn to live with. I think of it as an imbalance.
276
SEXUALLY TRANSMITTED DISEASES
Since I know it’s related to stress, I keep myself in as
good physical condition as possible and try not to get
too upset about it.
The one good thing I can say about herpes is that tt
keeps me honest in taking care of myself. When I feel my
vulva start to tingle and ache, it’s immediately a reminder
to me to slow down. I take long, hot baths. I try to think
relaxing, releasing thoughts and send healing, calming
energy to that area. Sometimes I meditate.
Humor is the best way of coping with herpes. There is
so much serious, scary sluff about it. You ve got to rec
ognize that it’s just one of the bad tricks people have to
live with.
Herpes may be easier to cope with if you feel com
fortable enough to talk about it openly. Some people
manage to talk themselves out of recurrences.
What turns out to be really useful is when my family
and I talk about the viruses. We say things like, ’’They
don’t want to come down now. Its much cozier up by
the spinal cord where they are. The weather is pretty bad
out here and everyone’s too busy to pay them much at
tention.’’ I think what it probably does is calm me and
ease whatever is bothering me. Who knows? Maybe they
hear! All I know is that sometimes after I get the warning
aches we sit at dinner having those discussions about
how my little herpes viruses should stay where they are,
and they don’t come!
The Herpes Resource Center (HRC), an organization
with local chapters throughout the country, provides
support, information and self-help groups for people
with herpes. It also publishes an informative news
letter called HELPER. You can join by sending five
dollars and a stamped, self-addressed envelope to HRC
(see Resources).
Syphilis
Syphilis is caused by a small spiral-shaped bacterium
called a spirochete. You can get syphilis through sex
ual or skin contact with someone who is in an infec
tious (primary or secondary and possibly the beginning
of the latent) stage. A pregnant woman with syphilis
can also pass the disease to her unborn child.
Syphilis spreads via open sores or rashes containing
bacteria which can penetrate the mucous membranes
of the genitals, mouth and anus as well as broken skin
on other parts of the body.
Symptoms
Once the bacteria have entered the body, the disease
goes through four stages.
Primary
The first sign is usually a painless sore called a chan
cre (pronounced “shanker") which may look like a pim
ple, a blister or an open sore, and shows up from nine
to ninety days after the bacteria enter the body. The
headache, fever (S2)—-
IL
hair falling out (S2)-*^|
lips (SJ
— throat (S2)
i
whole body rash (S2)
fingertips (SJ
nipples (Sj)
genital area (labia, vulva, u
vagina (Sj, S2)
anus, buttocks) (S,, S2)
painful joints (S2)
SYPHILIS (S, = primary stage: chancre)
(S2 = secondary stage: red, sore area; rash)
Christine Boruiante
CONTROLLING OUR FERTILITY
sore usually appears on the genitals at or near the
place where' the bacteria entered the body. However,
it may appear on the fingertips, lips, breast, anus or
mouth. Sometimes the chancre never develops or is
hidden inside the vagina or folds of the labia, giving
no evidence of the disease. Only about 10 percent of
women who ger these chancres notice them. It you
examine yourself regularly with a speculum, you are
more likely to see one if it develops. At the primary
stage, the chancre is very infectious. The preventive
methods outlined on p. 266 work only if the chemical
or physical barrier covers the infectious sore. With o
without treatment, the sore will disappear, usually in
one to five weeks, but the bacteria, still in the body,
increase and spread.
Secondary
The next stage occurs anywhere from a week to six
months later. By this time the bacteria have spread
all through the body. This stage usually lasts weeks
or months, but symptoms can come and go for severa
• • years. They may include a rash (over the entire body
' or iust on the palms of the hands and soles of the feet),
a sore in the moath; swollen, painful joints or aching
bones; a sore throat; a mild fever or headache (all flu
symptoms). You may lose some hair or discover a raised
area around the genitals and anus. During the sec
ondary stage the disease can be spread by simple phys
ical contact, including kissing, because bacteria are
present in the open syphilitic sores which may appear
on any part of the body.
Diagnosis and Treatment
Syphilis can be diagnosed and treated at any time.
However, because syphilis is less common now man
in the past, medical care workers may confuse early
symptoms with several other STDs, including chan
croid, herpes and LGV (lymphogranuloma venereum).
Early in the primary stages a practitioner can look for
subtle symptoms like swollen lymph glands around he
groin, and examine some of the discharge from the
chancre, if one has developed, under a microscope (a
dark-field test). Do not put any kind of medication,
cream or ointment on the sore until a doctor examines
it (The syphilis bacteria on the surface are likely to
be killed, making the test less accurate.) Spirochetes
will be in the bloodstream a week or two after the
chancre has formed. They will then show up in a blood
test, which from then on, through all the stages, will
reveal the infection. If you suspect that you have been
^Some E useTto treat
gonorrhea do not cure syphilis.) Remember, mcubat on
can be as long as ninety days. A good description of the
different blood tests used can be found in A Book
About Sexually Transmitted Diseases (see Resources).
If you are sexually active with more than one partner
yphilis blood
or if your sexual partner is, request a syphilis
cvcline pills for those allergic to penicillin is the treat
ment for syphilis. Since people sometimes have
relapses or mistakes are made, it is important to have
at least two follow-up blood tests to be sure the treat
ment is complete. You should not have sexual inter
course for one month after receiving treatment. The
first three stages of syphilis can be completely cured
with no permanent damage, and even m late syphilis
the destructive effects can be stopped from going any
further.
Latent
During this stage, which may last ten to twenty years,
there are no outward signs. However the kactena may
be invading the inner organs, including the heart and
brain. The disease is not infectious after the first few
years of the latent stage.
Late
In this stage the serious effects of the latent stage
appear. Depending on which organs the^ac‘®"?^V
attacked, a person may develop serious heart^is“se/
crippling, blindness and/or mental mcapadty. With
our present ability to diagnose and treat syphilis, no
one should reach this stage.
Syphilis and Pregnancy
A pregnant woman with syphilis can pass the bac
teria on to her fetus, especially during the first few
years of the disease. The bacteria attack the fetus just
as they do an adult, and the child may be bom dead
or with important tissues deformed or diseased But
if the mother gets her syphilis treated before the s
teenth week of pregnancy, the fetus will probably not
be affected. (Even after the fetus has gotten syphilis,
penicillin will stop the disease, although it cannot re
pair damage already done.) Every pregnant vvoman
should get a blood test for syphilis as soon as she knows
she is pregnant and any time she thinks she may have
been exposed. If she has the disease, she can be treated
for it before she gives it to her fetus.
Men’s Symptoms
Men's symptoms are similar to women's. The most
common place for the chancre to appear is on the penis
and scrotum. It may be hidden in the folds under the
foreskin under the scrotum or where the penis meets
the rest of the body. In the primary stages, men are
more likely than women to develop swollen lymp
nodes in the groin.
278
SEXUALLY TRANSMITTED DISEASES
Men's symptoms
Genital Warts and Human
Papillomavirus Infections*
/
'
i
_ nitai warts are caused by the human papillomaviG «-HPV similar to the type which causes common
Tn warts The same virus causes invisible warts or
£t lesions on the cervix. HPV usually spreads dunng
-xual intercourse with an infected partner. While HPVr,used infections have not been associated with senXs complications in the past, studies now show that
women with HPV-caused lesions on the cervix prob
ably have a higher-than-normal risk for developing
cervical cancer. Unfortunately, these invisible cervical
£ are not easily detected by either the health care
practitioner or the woman with the infection.
•
labia
-ix
vaginal opening
ftagina
anus
GENITAL WARTS
Christine Bondante
Warts usually occur toward the tip of the penis,
- foreskin
• • and’ occasionally
’ - --»i-r on the
sometimes under the
scrotum.
Using
a
condom can
shaft of the penis or l---help prevent the spread of warts.
Diagnosis and Treatment
Diagnosis of warts is usually made by direct eye
exam. An abnormal Pap smear may indicate the presence of cervical lesions, but a colposcopy is usually
necessary to confirm this. Occasionally you will need
a biopsy to check for unusual cell growth, especially
if there are ulcerations (open sores) or a discharge, but
these are rare. If you have cervical warts or lesions,
get a Pap smear every six months for early detection
of unusual cell changes.
There are several treatments for warts:
1. Practitioners most often prescribe podophyllm so
lution (some say ointment is better). Apply it to t e
warts and wash it off two to four hours later to avoid
chemical burns. Protect the surrounding skin with pe
troleum jelly (eg., Vaseline). Sometimes several treatments are necessary, and they are not always
^Trichloracetic acid (TCA) is currently used by only
a small percentage of practitioners but appears to be
better than podophyllin in several respects. It is usu
ally equally effective and yet causes fewer problems
than podophyllin. The strength of TCA is more easily
controlled; it works on first contact with ‘he skin and
then stops in about five minutes, rediKing the dange
of scarring. It does not seem to provoke severe reac
tions as podophyllin occasionally does. Some doctors ;
use TCA during pregnancy, although no studies have
been done to verify its safety at that time.
3. Cryotherapy (dry ice treatment) or acid can freeze
or bum off small warts. This hurts briefly and some
times causes scarring. You may want a local anes^4. You can apply 5-fluorouracil cream. It may cause
Symptoms of genital warts usually appear from three
weeks to three months after exposure. During the presymptomatic period (as well as while they are pres
ent), warts can be very contagious, so it is advisable
for your male partners to use condoms if any of you
have been exposed to the virus. The visible genital
warts look like regular warts, starting as small, pain
less, hard spots which usually appear on the bottom
of the vaginal opening. Warts also occur on the vaginal
lips, inside the vagina, on the cervix or around the
anus, where they can be mistaken for hemorrhoids.
Warmth and moisture encourage the growth of warts,
which often develop a cauliflowerlike appearance as
they grow larger. Cervical lesions, though more prev
alent than the visible warts, cannot be seen by the
naked eye and have no symptoms.
irritation and discomfort.
5 Surgery or electrodesiccation (using an electric
cun-ent to destroy tissue) becomes necessary for very
large warts which fail to respond to other treatmenu.
This procedure requires an anesthetic. If you have a
cardiac pacemaker, the electric current may disturb
it, so be sure to tell your practitioner.
6. Recent studies suggest that laser beams applied
to warts is an effective treatment that does not attect
normal tissue or cause scarring. Some practitioners
recommend it particularly for HPV infections of the
cervix (warts and lesions). Local or general anesthesia
mav be necessary', depending on the number and size
of the warts. Only physicians specially trained to do
laser therapy should perform this treatment.
No matter what treatment you get, it is importan
‘See “Who Is at Risk of CIN or Cervical Cancer," p. 487.
279
CONTROLLING OUR FERTILITY
What to Do If You Think You Have an
STD
to Remove all warts, even those ms.de the vagina and
on the cervix, to keep the virus from spreading. Sexual
partners also should be treated.
Get a diagnosis as early as possible. Most STDs are
Genital Warts and Pregnancy
disadvantages of each are listed below.
ably due to the increasing levels of progesterone.
Private Physicians, Gynecology Clinic;!S
and Hospital Emergency Rooms (Varying
(
Fees)
Parid can cause birth defects or fetal death.
Many private doctors' offices, gyn clinics and hospiUl emergency rooms lack the
W do a routine gonorrhea culture (GC), muchJess te
for chlamydia or herpes. In addition, many practi
tioners in these places tend not to test readily eno g
if a patient is white and middle-class.
Other Sexually Transmitted Diseases
iere are many more STDs than we can cover in this
T1
chapter See Chapter 23, which deals with common
medical and health problems, for information on com
mon infections which can be transmitted nonsexually
2 well as sexually. Other STDs which are rare or tend
■ to affect men more than women (such as chancroid,
.. lymphogranuloma venereum [LGV], granuloma in' gtinale intestinal STDs and hepatitis B) are discussed
lithe newly raised “A Book About Sexually Trans-
The first time I asked a gynecologist for a routine gon
orrhea culture, he smiled with a comradely look tn his
”e 'ButIm sure no man you’d be involved with would
have gonorrhea."
On the other hand, they may be overly 4^!°^
about the possibility of STD in patients who are black
and poor.
If «se?is a ve^ tiny percentage of the general pop
ulation, but a very high percentage of those ^o have
is run down,
rare cancer
searchers are
are working
working on
on a vaccine for AIDS,
searchers
d uMmen who\7v" gtu/n AIDS generally have W
Women who have gotten
sex wi—---A few people have goUen
nee tthat
There is no evidence
,‘“* AIDS can spread in any way
transfer of body fluids. This normally
other than in the t.---- contact between people, ine
requires close, intimate
j are not very distinctive; if you
warning signs of AIDS a
of The’ following problems you could have
have any c.
- • ■ than AIDS. Symptoms
° — any of several illnesses other
■ a series form of pneumonia; rapid weight
include a serious
rsistent fatigue; fevers; drenching night sweats,
loss;
j- ’ pei
hoa- drv cough not otherwise explainable, enSd painhil lymph nodes in the neck and/or armpitf; and/or purplish nodules on or under the skin.
.„h
4
•
«
•
1
am
Public Health Clinics (Usually Free or
of Nominal Cost)
Public health departments run STD clinics throughSTD on a daily basis, most clinics have personnel ex
p.rt.nc.d in
('“i'’X”pubulhe«lih >a«l«r who answers q"'1''™*
3bo„, sin.
rfj.
0„IS
embarrassing.
Because clinics tend to be o'ercrowdei you may
by a hurried doctor
have a long wait before being seen .
for transfusions.
1-
280 -
Women and AIDS
While enumerating the cautionary steps necessary, for women
to safeguard against the AIDS virus. Dr. P.N. SEGHAL raises
important points of concern for the infected woman,
especially during pregnancy, childbirth and postnatal care
e
A cquired Immunodeficiency
/\ Syndrome (AIDS) is caused
/ Xby Human Immunodeficieny
Virus (HIV) which attacks and
destroys certain white blood cells in
a process that can take many years
and as a result of which the
infected person develops an im
mune deficiency and becomes
susceptible to a wide range of
opportunisitc infections and can
cers. In addition, at some point
and in some people, HIV may
attack cells in the brain, causing
neurologiccal and psychiatric prob
lems.
■ People infected with HIV are both
infected and infective for life. Even
when they have no symptoms or
outward signs, they can transmit
the virus to others. Transmission of
HIV virus happens only by three
modes: sexual intercourse or
donated semen; exposure to blood,
blood products or transplanted
organs or tissues; mother to
foetus/infant infection.
The HIV injection is spreading
rapidly throughout the world.
According to WHO estimates,
about eight million people were
nfected with HIV worldwise result
ing in 700,000 AIDS cases in
early 1990. HIV affects women,
men and children around the
world, a third or 2.5 million cases
being women.
Susceptibility and safeguards
AIDS has a profound impact on
women, both as an illness and as
a social and economic challenge.
Women’s lack of status within the
family and society heightens their
vulnerability to infection and other
consequences of the disease. The
stigma attached to AIDS can
subject women to discrimination,
social rejection and other forms of
violation of their rights. Women
who are based in the home usually
do not have access to information
about how HIV is and is not
transmitted. Even informed women
may have difficulties in protecting
themselves against infection. Ideally,
a woman needs to be confident
and assertive to ensure that her
sexual partner uses a condom. But
in practice, many women are
dependent on their male partners
for financial or other support and
so may be forced to engage in
unsafe sexual intercourse where the
alternative is having financial and
social support cut off.
Safe sexual practices reduce the
risk of passing HIV from one
person to another. The best
protection is to choose sexual
activities that do not allow semen,
vaginal fluid or blood (including
menstrual blood) to enter the
vagina, anus or mouth or to touch
the skin where there is an open
cut or sore as these fluids can
carry HIV. Specific safer sex
practices include: (i) a mutully
faithful relationship between two
uninfected persons (ii) using a
condom for all types of intercourse
- vaginal, anal and oral (iii) non
penetrative sex practices such as
hugging, kissing, nibbing and
masturbating (iv) reducing the
number of sexual partners (v)
avoiding sex when you have open
sores or any sexually transmitted
disease (STD) and (vi) avoiding sex
with partners who have the same.
While some practices are obviously
safer than others, more people will
change their behaviour if they have
a range of choices and can choose
the approach that suits them best.
HIV and childbirth
All pregnant women or those who
wish to have children in the future
should be informed about HIV infection/AIDS. They should be
educated on how the virus gets
transmitted and encouraged to
consider whether they risk infec
tion. Pregnant woman should be
told the following facts:
•
If the mother is infected, there
is a chance (between 20 and
40 per cent) that her unborn
baby may be infected.
•
The risk of transmission is
probably highest if the mother
becomes rftfected with HIV
during pregnancy or is already
showing signs of AIDS.
An infected infant may die
within the first few years of
life.
Where mothers are to be confiden
tially tested for HIV, they must
also be counselled so that they
fully understand the implications of
HIV testing. Testing should be
both voluntary and confidential.
Choosing to have a test could
influence a pregnant woman
suspected to be HIV infected to
review her decision to continue
with the pregnancy. There is at
present no firm evidence to sug
gest that pregnancy adversely
affects the health of an HIVinfected woman or accelerates the
progression of the disease.
•
Antibody testing of a new bom
April 1991
HEALTH for the millions
37
/
/
WOMEN MORE LIKELY TO
BECOME INFECTED
Woiren are three times as likely as men to become HIV-infected thr°^Sh “xu®1
MeXurse according to a review of studies ^onduded in Great Britain and the Uni
States by the Lifeshield Foundation and AIDS Prevenbon Chanty.
The i itisdy concludes that daily intercourse with a seropositive man will, on ar'
Luse a woman to become infected within a year. However a man hav.ng da.ly
intercourse with an infected woman would become infected afterar.average of two
year: and nine months - CDC, AIDS Weekly, January 15, 1990
infant should only be done where
Indicated for the clinical
it is clearly
t
pf
the
child. As such testing
care <
reliably
establishes the HIV
more
infection status- of the mother .
rather than of the infant, it could
be misused for Indirect
indirect testing of
the mother without her informed
informed^
consent. Newborns at risk of HIV
infection must be provided with
adequate monitoring and care.
If found to be infected with HIV,
both men and women of reproduc
tive age need to decide whether or
not to have a child and how to
protect their sexual partner from
HIV if he she is not already
infected. Detailed below are some
likely situations that couples might
face:
If a woman is uninfected with
HIV but her male sexual
partner is not, it is impossible
tor her to become pregnant by
her partner’s sperm without
tinning a high risk of becomng Infected with HIV as there
is no way of eliminating the
virus from the infected man’s
sperm. However, the woman
could be artificially inseminated
with a non-infected donor
sperm in countries where this
is available. The woman
should, however, carefully
consider whether she could
look after the child adequately
in the event of her infected
sexual partner facing grievous
illness or death.
If a woman is infected with
HIV but her male sexual
partner is not, the couple could
38
HEALTH for the millions April 1991
still choose to have a child,
even knowing that the baby
may be infected. However, the
woman must be artificially
inseminated with the sperm of
her partner since penetrative
sexual intercourse without the
protection of a condom could
result in HIV infection in the
man.
HIV-infected women who become
pregnant should be advised about
the risks of having an infected
child. Termination of pregnancy
should be offered as an option in
countries where this is legal and
safe but the final decision must be
made by the pregnant woman.
Whatever her decision, she will
need both special emotional sup
port and practical advice on how
to prevent others becoming in
fected with the virus. All health
care workers, particularly traditional
birth attendants and midwives,
should be trained to ensure con
tinuing care and support whilst
ensuring privacy and confidentiality
for the infected mother and her
child.
Transmission from mother to
child
Transmission of HIV from an
infected mother to her foetus or
infant is thought to occur in 2040- per cent of cases. Data col
lected so far suggests that women
who reveal symptoms of this
disease are more likely to transmit
the virus to their child (before or
during birth) than women who are
asymptomatic i.e. they have the
virus but do not show signs of
illness. Asymptomatic infection can
last eight or more years. It is also
possible that women in the first
Few
days
1
' or wefeks
' of* infection are
more infectious than at a later
stage when the infection could be
asymptomatic. This means that if a
woman is pregnant or breastfeed
ing at the time of infectior , there
may be a higher chance o HIV
transmission to her foetus or
infant. Transmission can take place
before birth (prepartum), diiring
birth (intrapartum) and after birth
(post natal).
Prepartum
HIV transmission, via the placenta,
occurs even in the first th'ee
months of pregnancy, in studies,
HIV has been found in foetuses
aborted within the first three
months with evidence to iuggest
that women who have AIDS have
a higher than average ratfe of
spontaneous abortions.
Intrapartum
Transmission of HIV from an
infected mother to her baby can
occur during birth, probably be
cause the newborn is exposed to a
large amount of HIV infected
maternal blood and secre ions
during delivery. Nevertheless,
studies comparing the rate qf peri
natal HIV transmission appear to
show no difference in transmission
according to the mode of delivery,
that is, whether the infaijt is
delivered vaginally or by ceasarian
section.
Postnatal
Handling and cuddling of her baby
by a mother with HIV infection
does not transmit HIV to the baby.
The risk of transmission via breast
milk is apparently very low except
if the mother is infected after birth
and sero-converts (become HIV
antibody positive) while breast
feeding. Risk from this source is
considerably lower when compared1
to transmission in utero or during
delivery.
dignity of HIV-infected people and
people with AIDS, to ensure the
confidentiality of HIV testing r.nd
to promote the availability of
confidential counselling and oT'cr
support services to HlV-Wer ■’
peopie-and people wit’. iDS *
The prevention and contrd >
AIDS ultimately relies on the
responsibility of individuals net
put themselves or others-at ris o;
HIV infection. This Cannot be
achieved in a situation where lac
of confidentiality may expose
individuals to stigmatization and
discrimination.
The service providers must be fully
aware of this need for confidential
ity in their contacts with women
who are pregnant or contemplating
pregnancy and who may be HIV
infected or at risk of such infection
or who are seropositive for HIV.
HIV positive and AIDS cases have
been denied access to health care
which constitutes discrimination and
an inequality of treatment amount
ing to a denial of human rights.
Interavenous'drugs and AIDS
*5V‘
The immunological, nutritional, psy
chosocial and child spacing benefits
or breastfeeding are well recogni
sed. Breastmilk is also Important in
preventing infections which could
accelerate the progression of HIVrelated disease in already infected
Infants. In situations where the
mother is considered to be HIV?
infected, and recognising the
difficulties in assessing the infection
status of the new bom, the known
benefits of breast feeding should be
compared to the theoretical but
apparently small risk to the infant
of becoming infected through
breast feeding. In many circum
stances, particularly where the safe
use of alternatives is not possible,
WORLD HEALTH. AUGUST 1983
breast feeding should continue
irrespective of the mother’s HIV
infection status.
Confidentiality
While it may be generally under.stood that HIV cannot be spread
by casual contact, the specific and
individual instance of an HIVinfected child or adult can unveil
deep-seated prejudices. It has also
been observed that the lack of
confidentiality in HIV testing causes
decreased participation in voluntary
testing for HIV.
in 1988, the World Health Assem
bly urged Member states "to
protect the human rights and
In the absence of an effective
vaccine or cure for HIV infection,
education on how HIV is transmit
ted and how e>$posure to it can be
minimized is the most important
means of reducing its spread
especially among people whose
habits make them prone to such
risk. Education must be provided
for the entire population so as to
reach all those at risk with pro
grammes specially designed to help
people understand the implications
of HIV infection.
Prevention of HIV Infection in
women of reproductive age and
voluntary contraception made
available to HIV-infected^ women
are two important means of
preventing mother to foetus/infant
transmission.
— Dr. P.N. Sehgal, Former Director,
National Institute of Communicable
Diseases Delhi, is currently Consult
ant with VHAI.
April 1991 HEALTH for the millions 39
• ;
•
Public Policy Division
Vnim-.tary Health Association of Indi:
Punishing the Victims
_ ? —.
___ • •
Officials help the spread of AIDS epidemic
by .... •
Shyamala Natarajan
XL5-
•
/■
k <&/<•
ffl
h
In July 1990, the Madras high court
Ordered
the release of four HIV posi
■
Mvc women
'detained at
'city.'
others had been —«
.
(under the Prevention of Immoral Trai fie Act (PITA) and sentenced to be
tween one and three years of detenuon
in a remand home. Whilc under deten
tion, they along with about twenty
-other women similarly detained, tested
positive for the Human Immunodefi
ciency Virus (HIV). After it was deter- _
minedthatihey were infected with the
possible precursor to AIDS (Acquired
Immune Deficiency Syndrome), a court
-ordcr was issued requiring the conun-ecd detention of these women,
women,, eve
even
ued
•after iheir.scntcnccs were served. The
rationale was
' v rationale
was that
that the
the best
best way
way to
to prepreK\-cnl
’-cnl ths
the spread of the infcciion to
io
others and to
io provide medical help to
io
these women would be lo isolate them
ihcm
r
_______________
•n detention for
an
indcfiniic rtrrtnfi,
period.
]
1 firsi
first met these women in the rcI mand home at Madras in May .19S>
I 'xhen
wncn Ii was doing
uumt, research
- ------- on
- dis' -hminmion against HIV posiuve people
mJ possible methods of rehabilna| -mJ
•J -’on. All of them had originally been
4??n//.
c
ich
;is
of defiant laughter. Some looked rig-
of the home was a kind, c
'
Who nevertheless made n abu d
y
dear that any mecun
HI p
live women could be arra g
j
With the consent of her supertor, who
eventually did agree, but refused to
make it official. She claimed that both
j had forwarded
. d
tmcnlhadbccnmisplaccd.
io ^=P^r more
a month of
visils and requests, 1 was althem. “No cameras, no
recorders, all interviews only m
P
cnce of
superintendent," I
tl p
was warned. ■
. .
I wailed that sunny morning in inc
supcnnlcndenl’sofficc. An ayah
oul into the verandah calling, AIDS
girls hey you AIDS, come here." From
my scat near the entrance 1 could see
curious knotsof girls forming qmd.ly
beside the pad’, to the office as a strag
gly line of ostensibly infected women
walked past. They didn't look atany-
back jf any of the women got
off.cc
had jusl
a
whcn on(, f
years old, tall and
them. 25 or 26 years oto.
strikingly attractive, suddenly started
shouting. “What do you mean by lock
ing us up here like this? Arc we sheep
or cows to be paraded around, to be
pv____and
_ rpncd
.:ad into,
poked
mto. to be stared at?
Look at mo—sec my hands and legs,
do I look like I am ill? How dare you
lock me up like this after I have fin
ished my sentence? Let me go I say, let
mc go or I’ll kill myself.' Turning to
me she cried, “Amma. what is the use
of all of you coming here?.Why don t
you help me gctoul? 1 have a little son
1 haven't seen for 3 years now." Sud
denly. her energy spent, she started
sobbing, wheeled from the room and
ran right down the way she had come.
Emboldened by her outburst, several
of die other women also demanded I
P
t
T ‘MBER65
i
_
•
;
One reason for this anomaly is clear. afforded the minimum procedural safe- keep litem there.
The court then appointed an advo- <
Though prostitution is legal, soliciting guards of the adversarial system or the
(in a public place) is not. The police- ’ rules of natural justice because they cate com f iissioncr to meet the women •
this—clausVto
’ pimp nexus uses L.l
1----- --- .ilSs. had not been furnished with copies of . tochcck if theirstay was voluntary. In
reports. Neither did dicy have her report the commissioner pointed i
advantage. The police pick up a woman medical
i
-------------------u-ii—.u.
«^,,, out that all the women said that diey
on the pretext of soliciting even if shc; the opportunity to challenge
the accursonlVshwpingfo’r’Vcg^
racy of the same, thus violating their wished to go home, and that, in spite of j
7 holds
H the threat of conviction • •-*-----under
1 ■* —Article 14 and Articled 1 having been at the home for five y ears, j
thepimp
rights
. er her
he? to
to demand
demand total
total obedience.
obedience. If
If ; of
of the
the Consititution.
Consititution.
they were ignorant of why they had :
over
—
*•*-—* been detained and were under die
soliciting were to be decriminalized, it■ 4 3)
Blood tests had been ‘done without
• -is unlikely that the women would so-b the consent of the detained persons impression that dicy were now cured.
licit in a truly public place (they are .- with no .precautions to protect their Gung the repore ^Madras high court
ruled on 17 July 1990 that the women
• much more desirous of anonymity than d confidentiality.
; their clichis). On the other hand, the- i 4) There had been invidious discrimi- be released as "it appears to us that
‘ilaw can then truly be applied to the nation against the women because not there is no justification for keeping
‘[^flickers while actually providing the aU women arrested under PITA and (these four) in the home.”
After the ruling , I approached the
I women themselves with more lever-:;i testing positive for HIV arc detained.
authorities
to let me meet with the
■S'Ce. :. .
•-•
‘ . In many eases the women arc released
women
so
that
I could counsel them
! * Discussion about AIDS as an issue, • • on bail before the the results of the
and
offer
help
or
rehabilitation if they
^and of the vulnerability of prostitutes blood tests arc known.
so
desired.
But
my
request was ig
in particular was something no official ;t- 5) Similarly, no attempts have been
nored.
I
had
no
way
of
knowing
whether
was willing to talk about One even y made to confine and isolate blood donors
the women had actually been released
told me that the AIDS file was closed, whose samples were HIV positive.
till I approached the Legal Aid Board
I wfotc to the public prosecutor in !■••
for help . Through them I heard that
November 19S9, pointing out the facts -j
• they had indeed been freed. However
of the ease Std requesting a meeting. I; • 7^%^
there was no way of tracing them.
also, sent copies of the letter to other s:
The story, unfortunately, doesn’t
ofdcials. The leuer was ignored. Nobody y
have
die traditional happy ending. The
was listening. Though it was bccom- :
women
arc out. probably back to sell
ing more and more obvious that the
ing
sex.
Not only arc other people at
magnitude of the problem would defy
risk
of
infection,
llicy themselves arc
any quick solutions, the general ten- ,
soon likely to require medical and
dency was to close the debate on HIV
psychological
attention which may not
and AIDS.
■ “ ••
,
In March 1990, I filed a writ of 6) For every infected prostitute there
available. Though these questions
habeas corpus in the Madras high court was at least one man infected
infected —die plague me, I still think it is wrong to set
seckLng the release of five of the women, ■ man who infected her—and possibly such a dangerous precedent — isola
whose*particulars I had. Though the ’ other men who were infected by her. ‘ tion in this ease — dial can only be
l
specific purpose was to obtain their. • No attempt had been made to identify self-defeating. On the other hand. I
release, it was actually an attempt to and confine these men.
feel that in die years to come a good
stimulate discussion on an issue thdt 7) There was thus gender discrimina- suppon system needs to be built around
‘_______ ________
‘
..
’ 1
’
screamed
for attention.
A' supporting
r ■lion
andJ prostitutes who----------were already the needs of such people. I believe
~ ■by 7
“ Sundernr“ ‘
■ i; sociological victims were being douaffidavit was filed
Dr. S.
advocacy has a limited role in the
who has been ; bly victimised, while many men, inaman,./-a psychiatrist
r_y----context of a complete absence of so
working unceasingly with prostitutes : eluding their clients and infected pro
cial support Realising this, several
to promote awareness on sexually trans- 1 fcssional blood donors, were not being
non-government
organisations in the
j‘-.____ /CTr>.\
A ir^C T~kz»
/'nnfinArtor
rxrisolated.
icr,lntcrt.
minedj diseases
(STDs) and AIDS.
The confined
state
arc
now
looking
al education,
"‘'petition argued that:
'• •
• • . •.-di r The authorities’ reply merely subcounselling
and
care
projects
in the
1) The detention of the women bc- r' miued that the women were being
area
of
I
IIV
and
AIDS.
yond their period of sentence was held al the remand home on their writ
However, the larger issue of prosti
ten request for medical treatment; that
without die authority of law and
tution
and helping women engaged in
the women posed a danger to society;
amounted to a violation of their rights
commercial
sex to be able to protect [
and dial, in the absence of any agency
under Article 19 (i) (d) and Article 21
themselves
from
infections rcir.a:."<
willing
to
rehabilitate
them,
the
home
of the Constitution.
J
had a responsibility towards society to unresolved.
2) The detained women had no: been
■w
9
NUMBER 65
//O (
4 N G AL 22^
.infected with the disease who paid to didn’t seem to care. One madam
screamed at me:"V/hatcondoms? WeU
have sex with them bet did'-not use a
i not - lose our busincssl Just go away alid
leave us alone. Don't come nosing
de enubnand reported that they hadn’t possible to tell from a persons appear
Sowed ^o talk to lawyers “Help anee if they are HIV pos.uve. Appro- around here. I take my girls to die
doctor regularly.-a private doctor, not
oleasc ” whispered
mJi please,
whispered a
a young
young girl,
girl.. prime use of a condom isatprcscntth
dll these government chaps...If any
xfinl v n’ota day over sixteen, possi- • best precaution to adopt to keep ro
girl fallsiill we’ll replace her. Mme is
cc*' ■.. . Her huge eyes swam in getting infected during sexual intc
bly
younger.
unLhTdVars, her childish plump face • course with someone of other sex who a clcanplacc. Notuan will pick up any
disease here." Obvously, die notion
co is candy threatened to erupt into sobs.
diat the client could be die cause of die
T hi nJ because
me that the men never use a con- infection hadn’t occurred to her. Or if
mTblood
because II slept
slept with
with differdiffer- :. told
^iXon^lXtoGoddrat
dom. When,J asked.them^^Je reason. it had, she didn’t seem to take it into
entmen.r ,
_
account
J '
hewiUcleanmybloodsoonsoIcango
^ey
he
will clean my blood soon so I can go
The mortal danger to women hav
back
home. I just want to be with my wckSSingiHwithanincur- ing unprotected sex with HIV positive
^ISwEc^^n
rnfthcr. She will take care of me.” The
men wasnT a salient issue for die bmihcl
owners, nor did they make any efforts
asked. “Now’ that they _• once or
M sr.'c'/Scir senrace periods. . lira IMS vlsll Mk
* »lra'™ to devise means whereby the women
risk there was in getting.treatment for might acquire more jx>wcr to negoti
ate safer sex with clients.
The women talked about other is
to U!
. weren’t aware that there is no treat- sues. They told me that the only thing
bCSt..* ’
; J;,
■ ”•
“ ' ’ ’ ' ,
nature mem for AIDS, that all those who
that would give them more security
: Afekridwlcdging the illegal nature ment
>tcnU0D me auu™ — ... become HIV positive eventually get and help them negotiate directly with
of th? detention, the aulhorites howi-.
oiii .that
Out it
ever pointed olit
it was
was their
their re.
re- ,1.
, AIDS,. and that it has proven so far to the client was to gel the police off their
sponsibiiity 10detain the women since •; be mvanaMy
■
backs. Asked the girl who had threat
2. The)' fell they didn’t ha\c a choice.
ened
to kill herself: “When my hus
ihjy would otherwise be a threat io In the brothels where they worked if
society. To be (air* it was obvious that, . they said they wouldn’t have sexual band beat me every night, did the
th * women’s physical. needs were...... intercourse with a man unless he us^d government help me? When my child
adequately looked after. AU of them A a condom, they would be beaten to had to go to school, did the govern
ment pay for his uniform or books or
were on a special diet and received .
force them into it. In addition, they all the other things that even a so■ m Tular medical attention. Though they
were housdd separately, they satalong might not bejed
called free school asks? If you people
The brothel owners 1 spoke with
can’t give me a good job so I can earn
ih
the
uninfected
girls
m
the
class.
w;
enough to cat well and educate my
robm and ate their meals together as
children, what right do you have to
well. B ut it was easy to see that neither
lock me up for doing die only thing I
ih: infected women nor the others in ,
know to do to survive? Why don’t you
ih: home, including the staff, had any ,
lock up the man who carnc to sleep
char idea of the nature of HIV and •
with me. why don’t you lock up die
A [DS, the ways in which it was spread
pimp who hired me into this, why do
ar d the effects it could have on people.
/. you people keep harassing poor girls
The women were constantly referred
/ like me who don’t know anything?”
to as "pools of infection’’ and ’Threats
Indeed, even a cursory examinadon
to society" without any consideration j
,
ofcourt
records in any state will reveal
qf
the
fact
that
they
had
whatsoever
that
there
arc almost no eases of con
Jiginaliy
been
infected
through
some
01
viction
of
brothel owners or pimps
7
who
himself
was
continuing
to
■
m|an
despite the fad that PITA is aimed
spread it to every other woman he
primarily at stopping trafficking in
sf epi with, and sometimes through her
women. Though prostitution is legal,
her
unborn
child.
Besides,
many
of
to I
It
invariably the women who aic
die men were likely professional do
liircaiencil. bullied and arrested by the
nors cf biood as well and the infection
: police and subsequently convicted by
could spread through that route too.
It is fairly certain that all these
tiu courts.
women were infcvtcd V)' men already
du ir release' asking to be returned to
“25SXSSS.
t
v»
K
•8
I
Women’s wtortilW
prema
ramachandran
impact followed and today we have
THE second half of the 20th century global data on the epidemiology,
witnessed tremendous improvement pathophysiology and clinical mani
in maternal and child health. Impro festations of aids in these two vul
ved diagnostic tests, anaesthetic and nerable segments of the population.
operative techniques, availability of Based on this data, measures to
banked
blood, antibiotics and minimize the adverse impact have
other drugs gave
™
been defined, which include provi
unparalleled opportunity to tackle sion for care of aids cases and
the health problems of women and seropositive persons, strengthening
children. Efforts to reach services of MCH care and suj^gortive services
to the needy through the primary and health education.
health care approach were ^king
headway. Everyone optimistically
Of the three major modes of Hiv
assumed that since progressive transmission world-wide, sexual
global improvement in hea th status transmission has proved to be the
is inevitable, health for a l in India most inefficient method of spreading
would be achieved, if not by 2000 Hiv infection; the risk Oi infection
AD, at least a couple of decades has been estimated to range from
later.
1/1000 to 1/100 exposures. However,
IU1 hindsight, one' can see that because of the large size of the popuWith
availability of con- Iation and frequency of the exposure,
the widespread
'
.
and
sexuai transmission accounts tor
traceptives to prevent
p.------ --pregnancy
« rirrr
.
-------ofc STDs over 75% of infections. Women are
antibiotics for the treatment
led to behavioural changes in the more likely to get infected by, rather
population. The increased sexual than infect, men. The presence of
promiscuity which resulted set the sexually transmitted diseases, espe
stage for a potentially explosive STD cially ulcerative lesions of the geni
epidemic. Looked at from this pers talia, increase the risk of Hiv
pective, the aids pandemic has all transmission.
the inevitability of a Greek tragedy.
Parenteral transmission due to
It nevertheless came as a rude shock
blood/blood product infusion is the
to us.
most efficient method ot transmis
By mid-1980s it was realized that sion
with the estimated transmission
women and children are among the rate being 90%. However, with
worst affected segments of the popu improved coverage ot screening ot
lation. A rapid assessment ol the
SENCINAR 396 — August 199-
21
blood/blood products, this mode is
likely to become rare. The risk of
parenteral transmission following the
use of contaminated syringe needles
is estimated to range from 1-5/1000
exposures. It accounts for the obser
ved hiv infection in ivd users, and
accidental infection in health care
delivery. Parenteral transmission is
currently estimated to account for
5-10% of hiv infections in different
regions but is likely to become less
common by 2000 ad.
Perinatal infection occurs in 20-
50% of infants born to seropositive
women. It is estimated that perina
tal transmission accounts for 1-10%
of all infections in different regions.
The contribution of this mode of
infection is likely to increase oyer
the next decade when hiv infection
becomes more prevalent in Asia.
It is estimated that the average
duration of the asymptomatic period
in hiv infected adults may last from
8 to 10 years. Once the symptoms
develop, progression of the disease,
especially in developing countries, is
rapid: the majority of aids cases die
within two years of diagnosis. The
progression of hiv infection in in
fancy and childhood is also rapid:
50% of the infected infants die by
the time they are two years old and
over 90% do not survive five years.
The illness and eventual demise of
the mother from hiv infection has a
catastrophic impact on the well be
ing of the entire family. The infected
infants may succumb more rapidly
in the absence of maternal care
while the uninfected infants face the
grim prospect of becoming orphans
early in childhood, with all the
attendant adverse consequences.
22
Using all the data available from
different sources, who estimates that
currently there are 8 to 10 million
Hiv infected persons in the world.
Of these, more . than 3 million are
women: and a million are children.
Over two-thirds of all the infected
persons live in a developing country
and have little access to health care.
In the USA and Europe, the hiv
epidemic curve appears to be plateauing. In Africa and Asia, however,
the steep rise continues. Currently
2 million hiv infected persons live
in the US; 5 million in Western
AIDS
Europe; 6 million in Sub-Saharan
Africa and 1 million in Asia. Unless
very effective intervention program
mes are implemented, the number of
hiv infected persons in Asia is ex
pected to cross those in Africa by the
mid-1990s and by the year 2000,
Asia might have the largest number
of hiv infected persons in the world.
who estimates that by 2000 AD
about 40 million men, women and
children are likely to be infected by
hiv, with the cumulative number of
aids cases around 10 million. The
heterosexual and perinatal will be
the most common modes of hiv
transmission, and over 75% of the
infected persons will be living in
developing countries.
Providing
.health care for these is likely to fur
ther strain the already severely strain
ed resources of these countries. By
1989 an estimated 1.5 million unin
fected infants were born to hiv in
fected women. Most of them are
likely to lose one or both their
parents as a result of aids and be
come orphans. This figure is also
likely to double by the year 1992.
Providing appropriate support to
these homeless waifs until they be
come adults is a task that is likely
to tax the welfare departments to the
utmost.
rior to the advent of aids, un
had projected that the ' under-five
mortality rate would decline from
164 per 1000 live births in 1988 to
130 per 1000 by 2000 ad. Current
estimates indicate that under-five
mortality was 166 per 1000 in 1988
and the figure is likely to rise to 185
by the year 2000. A similar trend is
likely in maternal and adult morta
lity rates, hiv has thus wiped out
the decline in mortality rate achieved
by three decades of toil.
aids will result in the death of
men and women in the reproductive
age group, leaving the elderly with
out support. Women and children
will become doubly vulnerable as
aids casualties and aids survivors.
The economic impact of the disease
is likely to become very important
in the long run. Hospitalization for
hiv related diseases may overwhelm
the health services resources and
manpower by the mid-1990s. Avail
able data show that in some African
countries 80% of hospital beds are
filled with aids patients and that
aids will claim up to half of all na
tional expenditure for health in
some countries.
There is no doubt that the direct
' >sts of aids will be substantial, but
e indirect cost of the pandemic will
w even more prohibitive. There will
be a decrease in workforce producti
vity due to hiv infection. Millions
of young adult lives will be lost
lesulting in a dramatic loss of poten
tial productive years to society, aids
related sickness and deaths will
affect the urban industrial sectors to
begin with, but later, it is likely that
agriculture, which remains the back
bone of many areas, will be affected.
Eventually the entire socio-economic
system will be eroded resulting in a
tremendous negative effect on natio
nal development.
India has the unique distinction
of being the first country in the
world to initiate systematic nation
wide sero-surveiHance among asymptomatic men and women belonging
_ _
‘ low
_ risk groups» to ob
to
high___
and
tain information on the magnitude
and major modes of hiv transmission
before aids cases were reported from
the country. In 1986, icmr organized
a national sero-surveillance .pro
gramme in close collaboration with
Directorate General of Hea th Ser
vices (dghs) and the state health
services. The programme util zed the
existing health care infrastructure
with minimum essential additional
inputs.
The data collected by the national
network of reference and surveillance centres cduring the first six
months showed that hiv infectioni
ts of the
was present in different parts
ual pro
country, and that heterosexual
miscuity was the major mode of
-f
tough the
transmission in India. Although
»v/l
next 18 months of the survey
indica
led that the magnitude of infection
ted
in India was low, it became obvious
that the infection is not confined to
promiscuous men and women, hiv
infection was detected among blood
donors, spouses of promiscuous per
sons, children born to seropositive
women and persons receiving blood/
blood product infusions. It was also
clear that the seropositivity rates
among promiscuous men and women
and blood donors had shown a steep
rise between 1986 and 1991.
phase and do not know that they are
infected.
Right from the inception of the
programme, icmr investigated not
only the so-called high risk groups—
promiscuous men and women, reci
pients of blood/blood products, iv
drug users—but also low risk groups
like pregnant women. Detection of
asymptomatic seropositive persons
in the low risk group had to a large
extent contributed to the realization
in the country that hiv can affect all
segments of the population, leading
to a consequent reduction in the ten
dency to discriminate against hiv
positive persons.
It has been variously estimated
that between 100,000 and 400,000
women in India are infected by Hiv.
Every year, approximately 20,000
out of the 24 million deliveries in
India are likely to occur in seroposi
tive women. Prior to the hiv epide
mic, India and Sub-Saharan Africa
had similar MCH profiles. The modes
of Hiv transmission in these two
areas are also similar. The major
difference is that apparently hiv en
tered India a decade later. Effective
implementation of intervention pro
grammes can avert the re-enactment
of the Sub-Saharan tragedy in India.
Based on the available data,
estimates that there are bet
ween 0.4 million to a million Hiv
infected persons in India. Estimates
on the magnitude of the silent epide
mic of hiv in India based on data
collected by the icmr sero-surveillance, together with the data from Thai
land, led to the upward revision of
who’s estimates of hiv infection load
in Asia. This, in turn, has led to the
shift in the focus of global aids con
trol programmes to Asia in an effort
to slow down the epidemic, so that
the Sub-Saharan tragedy is not repea
ted again.
icmr
The first seropositive persons de
tected in India were sex workers in
Tamil Nadu. Since then, centres in
different states undertook the screen
ing of a substantial number of sex
workers. Data from these studies
indicate that there had been a slow
but steady increase in the seropositi
vity rate from 10% in 1986 to 30% in
1991. Intervention programmes are
currently underway in Bombay and
several other cities to reduce hiv
transmission to and from commer
cial sex workers.
Seropositive pregnant women (de
tected by screening during preg
nancy) and pregnancy in known
seropositive women were reported by
sero-surveillance centres in as early as
1986-87. Data from the icmr serosurveillance indicate that between
one-third to a half of the hiv sero
positive persons in India are women.
Most of them had been infected by
heterosexual transmission; many do
not belong to high risk groups. The
majority are in the asymptomatic
(Contrary to initial reports, preg
nancy does not have any adverse
impact on the course of hiv infec
tion. Immunodepression associated
with pregnancy does not accelerate
the progression from the asympto
matic phase to aids and death, hiv
infection per se does not appear to
have any adverse effect either on the
health of pregnant women, the
course of pregnancy, labour, peurperium or lactation. It readily cros
ses the transplacental barrier. Avail
able data indicate that intrauterine
infection occurs in 25 to 50% of
pregnant women. There is some
evidence that the risk of iu infection
is lower in asymptomatic women,
especially those who have a higher
antibody titre. The risk of intra
uterine infection is higher in women
who are viraemic—these include
women who have very recently acqui
red the infection and those with
aids. Infection risk is reported to be
higher in women who had earlier
delivered an infected offspring.
In the last two years, there has
been speculation about whether the
use of drugs that reduce viraemia,
such as azidothymidine and CD4,
during pregnancy would increase
foetal salvage. However, to do this,
one would have to weigh the possible
adverse effect of these drugs on preg
nant women and the foetus against
potential benefits. There may also
be major ethical problems in con
ducting even clinical trials to test the
hypothesis, hiv infection is associa
ted with a higher rate of premature
delivery and Intrauterine growth re
tardation. It is possible that at least
part of this association might be
attributable to coexistent risk factors
like smoking, drug addictions and
anaemia in Hiv infected women
The fate of the unborn child is
the major reason for concern in the
context of hiv infection in pregna
ncy. To prevent these potential
calamities, medical termination of
pregnancy (mtp) may be done in the
first trimester, if the^patient wishes
it. Women who want to continue
pregnancy should be provided with
adequate and appropriate antenatal,
intrapartum and postnatal care. In
tensive neonatal care facilities should
be available for looking after the
low birth weight neonates. Every
effort should be made to counsel the
mother to adopt appropriate contra
ception soon after delivery and teach
her the importance of correct and
consistent use of condoms. Stringent
precautions should be taken to pre
vent the accidental spread of hiv
infection while providing health
care, especially during delivery.
Screening for hiv during pregnancy
along the lines of screening for
syphilis during pregnancy has many
ardent advocates. The major reason
for screening for STDs like syphilis
in pregnancy is to provide therapeu
tic intervention to prevent iu infec
tion. This justification does not exist
for hiv. Counselling for mtp in early
pregnancy in seropositive pregnant
women may providothe ratipnale in
our country, but there are several
practical problems that come in the
way of the proposed hiv screening
in India: (a) most infected women
do not belong to any recognizable
risk groups; (b) screening of all preg
nant women is impossible because
the majority do not attend antenatal
clinics; and (c) screening facilities
are neither available nor affordable.
Most infected women will thus con
tinue to remain undetected.
Inhere is, nevertheless, a need to
screen all pregnant women. The
advantages of undergoing Hivtesting
are many and should be clearly ex
plained. In India, the majority of
the people, even those in high risk
groups, are not seropositive. Screen
ing would therefore provide these
women with proof that they are
uninfected, relieve them of their
anxiety and possibly ensure that they
seminar
396 — August 1992
23
do notfencounter any future risk of
h’tv infection*
For those with hiv infection, there
are now drugs to prolong the asym
ptomatic period and alleviate their
suffering. These women could take
steps to ensure* that they do not
spread the infection to their partners/family. Identification of seropo
sitive pregnant women and follow-up
of their children is the only method
by which children requiring special
care in the future could be identified
long before the need arises. The time
available could be utilized in identi
fying the uninfected children who
require societal support for their
upbringing, so that they do not
suffer the severe adverse effects of
being ‘aids orphans’.
It is imperative that safe and effec
tive contraceptive care is provided
for all seropositive women because
of the known adverse consequences
of hiv infection during pregnancy.
In developed countries, condoms
and spermicides containing monoxynol-9 have been advocated because
they afford protection not only
against pregnancy but also against
hiv infection. In India, the current
acceptability and use effectivity of
condoms is very low. Incorrect and
inconsistent use of condoms could
lead to a false sense of security and
consequent increase in hiv infection
rates. It could also result in. unwan
ted pregnancies with all the atten
dant hazards to the mother-child
dyad. In view of this, it is essential
that health education regarding the
advantages of condom use, the cor
rect method of use and the need for
its consistent use be initiated to im
prove acceptability and effectivity.
Subsequently, condom promotion for
the prevention of aids could be
taken up.
24
So far, no adverse interactions
between any of the currently used
contraceptives and hiv infection have
been reported. In view of the known
adverse consequences of pregnancy
in hiv infected persons, it is essential
to provide safe, effective and suitable
contraceptive care to all hiv infected
individuals. The choice of contracep
tive for individuals should take into
account the risks and benefits of the
method, life-style and contraceptive
preferences of the individual, availAIDS
ability of the contraceptive and exist
ing health care facilities. However, in
addition to the use of contraception
of their choice, all seropositive per
sons should be taught to correctly
and consistently use condoms for
reducing the risk of hiv transmis
sion. It is essential to ensure that
needles, syringes and other equip
ment needed for fertility regulation
are properly sterilized before use.
Due to limited laboratory facili
ties, lack of infrastructure and the
prohibitive cost, it is not possible to
screen all contraceptive advice see
kers for hiv infection in India. Thus,
in the majority of cases, contracep
tive care will have to be provided
without any knowledge of the hiv
infection status of the individual. The
who expert group on contraception
and hiv infection has recommended
that under these circumstances, con
traceptive care can continue to be
provided according to the existing
guidelines, even though the hiv sta
tus of the person is not known.
Hiv has been isolated from breast
milk. Intense research efforts over
the last four years have resulted in
documentation of a few instances
where the infant might have been in
fected through breast milk, but this
mode of hiv transmission is very rare.
All available data suggest that breast
feeding v/iil protect the hiv infected
from other infections and may even
prolong their survival period. In
India, this advantage will by far out
weigh the small potential risk of hiv
infection through breast feeding. The
refore, breast feeding is desirable in
children born to seropositive mothers.
to concern about the effiqacy and
safety of immunization of h v infec
ted infants and children. Experience
with live and inactivated vaccines in
Hiv infected children suggests that
the immunization is free fro n major
short-term side effects. R. sks and
known consequences of na ural iir
fection are likely to be gra er than
the risks associated with vaqcination,
even with live attenuated vaccines.
Taking all these factors in|o consi
deration, WHO has recorpmended
that all asymptomatic hiv infected
children receive all standard vaccines, both live and inactivated; and
that those with arc/aids symptoms
should receive all other vaccines ex
cept BCG.
Since extensive hiv testing of preg
nant women is not possible in deve‘ / j countries like India, the
loping
majority of seropositive infants remain undetected. At presentt there
are no tests for detecting infected
i.
infants. Under these circuiyistances,
who has recommended that all
asymptomatic infants receive all
standard vaccines iirrespective of
their hiv status, known or IUnknown.
The existing immunization programmes in the country should therefore
be vigorously pursued.
In India very few of the infected
mothers can be detected because
universal hiv testing is not possible.
Breast feeding is essential for in
fant survival and growth especially
among poorer segments of the popu
lation, because infant food formulae
are neither affordable nor safe.
Hence breast feeding by the biolo
gical mothers should continue irres
pective of the hiv infection status of
the mother or infant, known or
unknown. Promotion of breast feed
ing should continue to be the natio
nal policy.
rP
A 1he advent of hiv infectipn in the
community is yet another reason to
intensify efforts to providij optimal
Providing appropriate
mch care.
contraceptive care to all eligible
women would
\' substantially reduce
the birth of infected infants. It is
essential that all aseptic precautions
are meticulously adhered to during
the provision of antenatal, intra parturn and contraceptive care , so that
accidental Hiv infection is prevented.
Breast feeding, which is the best
form of infant feeding, should be
encouraged as the method Of ensuring infant survival and growth and
birth spacing. Irrespective of hiv inin
fection status, all apparent y healthy
infants should continue to3 receive
immunization against the six major
vaccine-preventable diseases. With
the introduction of mandatbry scre
ening of blood/blood products, the
risk of Hiv infection in children
through parenteral transmission is
likely to be minimized.
The increasing prevalence and
awareness of hiv infection has led
Public concern regard ng AIDS
stems from the knowledge hat there
is no curative therapy or prophy
lactic vaccine for this infection, hiv
per se does not kill; it is infections
and malignancies that occur in the
immuno-compromised persons that
are responsible for the ensuing
suffering and death. The available
meagre data from India indicate that
tuberculosis and amoebiasis are two
common infections in immuno-com
promised hiv infected persons. How
ever, safe and effective drugs for the
treatment of these two infections are
now available. Also global research
efforts have resulted in better diag
nostic tests and effective drugs
(though many do have severe side
effects) for the treatment of several
opportunistic infections seen in aids
patients.
aids patients require hospitaliza
tion for the treatment of acute
pathogenic or opportunistic infec
tions and life-threatening emergen
cies. Many require emergency or
elective surgical intervention. Malig
nancies occurring in aids patients
also require appropriate manage
ment. Facilities for all necessary
investigations and therapeutic proce
dures should thus be made available
in the nodal hospitals. Every effort
should be made to provide optimal
care for aids patients, especially
during acute infections ana lifethreatening emergencies, even tho
ugh this effort is likely to strain the
‘ afready meagre monetary and man
power resources available for health
care in India.
During the chronic and terminal
phases of their illness, aids patients
require symptomatic treatment.
These patients have to be provided
with care in hospices so that they
can spend the last days of their lite
in comfort and with dignity. Special
efforts must be made to explore the
feasibility of involving non-governmental/voluntary agencies for provi
ding this type of care.
The aids pandemic caught the
world in its most complacent decade
when all seemed well on the surface
and progressive improvement in
health and prosperity appeared to
be inevitable. With startling sudden
ness the Htv pandemic ripped this
surface veneer exposing the ugly
realities, shortcomings, weaknesses
and prejudices not only in the health
system but in the entire social struc
ture. The initial reaction was pre
dictably panic, passionate protests
and aggressive postures or depression
and desperation.
But soon the challenge brought
forth the best in mankind—the orga
nization of a truly global systematic
effort to define the problem and
evolve and implement effective mea
sures to alleviate the suffering and
control the infection. Never before
had so much been done in so short
a time. Very high priority is accord
ed to research efforts directed at
finding a drug to cure or a vaccine
to prevent aids. If one is found
soon, the social and ethical problems
may vanish overnight and aids will
become yet another remediable STD.
It is however, unlikely that dur
ing this decade there will be a vac
cine or drug for the prevention or
treatment of aids. Hence our efforts
should be focused on prevention of
hiv infection. Its spread can readily
be prevented by mutually faithful
monogamous sexual relationships.
In persons who cannot follow this
golden norm, the correct and consis
tent use of barrier methods such as
the condom could minimize the risk
of Hiv infection. Massive health
education campaigns of the kind
never before attempted in the health
sector are underway, using all chan
nels of communications to spread
information about aids so that every
individual can take steps to prevent
the spread of hiv.
Women have a very special role
to play in the containment and con
trol of hiv epidemic. They have to
protect themselves, their spouses and
their children (born and unborn).
They have to provide care and com
passion to those who are already
infected so that they spend their hie
in comfort and die with dignity If
the breadwinner of the family dies,
they have to take on the additional
role of the wage earner so that their
family does not suffer economic dep
rivation. Last but not least, the
majority of mchcare providersand
health educationists in India are wo
men: it is possible that they may
succeed in providing appropriate
counselling and care through inter
personal channels.
seminar
396 — August 1992
25
Sexuolily
MIRA
S A VARA-
ABOUT four years ago, an official
for the Indian Council of Medical
Research, New Delhi, spoke at the
International aids conference in
Montreal. He maintained that ‘aids
cannot, will not be a problem in
India because we are a traditional
society,* because we are unlike the
decadent West, where the pill
brought about a sexual revolution,
with promiscuity and homosexuality.
Hardly five years later, and world
authorities believe that India will
probably be the epicentre for aids
in Asia. Estimates about the number
of hiv infected persons in India are
many: ranging from 40,000 (in a
who publication) to 0.5 million
(accepted by the International Deve
lopment Agency and many aid
organizations) to 2.5 million (attri
buted to T. Jacob John of the
Christian Medical College, Vellore,
the first doctor to report of the pre
sence of hiv in India). The estimate
of the number of full blown, aids
cases was about 115 in March 1992?
But it is commonly agreed that the
official numbers of hiv infected arc
grossly under-reported because of
our inadequate medical infrastruc
ture.
These figures have caused serious
concern, and a massive amount of
money is pouring in for AIDS-related
work. Estimates keep changing, with
the official government amount just
for the state of Maharashtra, where
the most aids cases have been
detected, often being quoted as over
Rs. 300 crores. This does not in
clude the aid given by private
agencies to NGOs.
In this article I shall argue that
much of the AIDS-related educational
26
1. Lal, Shiv,‘aids/hiv Infection in India
—National Programme and Future Strategies/Policies*. CARC Calling* Vol. 5, No.
1, January-March 1992.
AIDS
work currently being unde-taken in
India is irrelevant because here has
been no attempt to understand and
put sexuality into the Indian con
text. Prostitution, generally consi
dered to be the hot-bed of (nfection,
has been targetted for a massive
onslaught. But since prostitutes are
the wrong audience, the messages
fail to make the desired impact.
Moreover, the messages themselves
are culturally irrelevant since Indian
understanding of the cajuses of
disease and health differ. I shall
therefore attempt to put sexuality in
a socio-historical context by examin
ing the conditions under which the
homosexual community developed in
the US. The socio-economic scenario
in India and the implications for
sexuality will then be discussed.
It is widely believed th it aids is
caused by the hiv virus. Recently,
however, a controversy his deve
loped about this, with several top
medical researchers, including Luc
Montagnier who discovered hiv in
who first
1983, and Peter Duesberg Uho
mapped the genetic structure of such
viruses, believing that aids is not
caused exclusively by hiv. Tiey argue
that the virus does not kill the cells
of the immune system, but that the
disease occurs when the immune sys
tem gets mis-programmed and begins
to commit suicide in the presence of
certain co-factors. Duestjerg also
maintains that aids is not nfectious
and is the result of other factors that
damage the immune system includ
ing ‘recreational drugs such as
cocaine’?
The reason for mentioning this
detail is that all current educational
intervention programmes are based
-
2. Bidwai, Praful, ‘aids: Panic More
Widespread than hiv’, Times f India, 11
May 1992.
on the fact that hiv causes aids. And
hiv is transmitted through body
fluids, one avenue being the exchange
of sexual fluids. It is therefore im
portant to keep in mind the ongoing
controversy about the hiv-aids con
nection. There is, after all, a large,
world-wide aids bureaucracy and a
multi-million dollar industry which
exists on the belief that hiv and
aids are connected. Any research
that could topple this belief might
therefore be prevented from reaching
the public.
F rom
of transmission, it is possible to see
them as being related to the differing
historical and social conditions. In
the West, societal changes were such
that there emerged a sub-group and
culture which could clearly be per
ceived as homosexual, making it
possible to identify aids with a
particular social group and thus be
seen as the Gay Plague. Such condi
tions did not occur elsewhere. This
is not to say that homosexual acti
vity in Asia and Africa did not exist,
but that the social context and
expression of such behaviour are
different in these societies.
for men-and women. With a long
historical tradition of greater access
to public space as well as gender
socialization that encouraged sexual
expression, gay men could meet
more openly in bars, parks, bat ft
houses. Boston, for example, had
about 24 bars for gay men, as
against one which served or‘y
women.
the Indian point of view,
It was in the middle decades of
this new development is extremely the 20th century that a gay sub
interesting, Western medical under- culture took root in American cities.
/_____ disease has The war years pulled millions of
standing of the V.
causes
beenU“based"on the germ theory. American men and women ^ron]
Eastern and more holistic
holistic^ methods
metnoos their families and small towns and
of understanding health have stres deposited them in a variety of sex
sed
sedUth7t
that iHsThe
it is the0 basic
basic balance^and
balance. and segregated, non-familial institutions.
For men, it was the armed forces;
ll&aiit*
v
“
»
*■'
—
—
,
health of the body which determines
meant
to the
whether
succumbss to
wiicinti a person succurn
o a for women it —
------ migrating
-o
_
•lodging
’ ‘
disease. The new developments tit cities and often
andJ-------working3
a holistic system far better. How- in virtually
virtuany all-female environments.
environments,
ever,•“since this article concentrates For a generation of young Amerion aids and sexuality, we will assu- cans,
war created a setting in
me for now, that hiv causes aids, which t0 experience same-sex love,
and that hiv >s
is passed through an affection and sexuality.3 At the same
__
* ’ fluids timej
exchange of' body
Blood the
is pill and birth . control
the connecone. But another, which is more movement was breaking
L.
’
A new
A
relevant here, is sexual fluids. Chan tion of sex with reproduction.
ces of infection increase with mul philosophy was emerging: sex was
tiple sex contacts, which occurs for pleasure.
• through affairs (unpaid sex), paid sex
and homosexuality.
The standard of living was also
It has finally been accepted that rising, together with the number and
there are no ‘natural’ sexualities; reach of consumer products. Ihis
and that sexual behaviour is socially allowed individuals to actually live
constructed; that the rates and forms a life dedicated to only pleasure.
of sexual expression vary across time With growing consumerism, the ad
and space, and that they differ for vertising industry increasingly star
different classes and social groups. ted to indulge in a not very subtle
In each society and sub-culture, the use of the erotic and sensual to sell
social meanings of sex differ, as does their products. The entire society
its place in the life of men and became sensualized, as it were with
women. In order to concretize this lips, breasts, cleavages, and skin
social construction of sexuality, we spilling out of every paper, magazine
will examine the conditions under and tv programme.
which the ‘homosexual community
The changes set in motion by the
developed in the US.
war continued after demobilization.
aids literature often talks about
As male homosexuals and lesbians
two different patterns of transmis- came to associate more freely, they
sion-that of the West, where it created institutions to bolster their
starts in the homosexual community, sense of identity. The sub-culture
and then filters into the heterosexual. that evolved took a different shapv
The other is the African (also appli
3
D^Emilio and Estelle B. Freedman,
cable to India), which is primarily
Intimaie Matters-. A History
fv
heterosexual. However, rather than in
America, Harper and Row, USA, 1988.
viewing them as two differing modes
TThe expanding possibilities
for
gay men and lesbians to meet did
not pass without a response, she
post-war years bred fear about the
ability of American institutions to
withstand subversion from real and
imagined enemies. Politicians first
latched on to the issue of homo
sexuality in February 1950 the
same month that Senator JosePh
McCarthy initially charged that
that the
the
Department of State was riddled
with communists. A Congressional
hearing was told that thousands Oi
sexual deviants worked for gov
ernment. In June 5950, a ^rmal
enquiry was commissioned. The en
suing reports charged that homo
sexuals lacked emotional stability,
and that they have a corrosive influ
ence on other employees. The cold
war against communism made the
problem of homosexuality even more
threatening, with the charge that
homosexuals could easily become
spies because their>deviance made
them prime targets for blackmail.
There was a remarkable increase
in the annual number of dismissals
from government service, the num
ber of discharges doubling with
each passing year. One study in the
mid-1950s estimated that over 12.6
million workers, i.e. more than 20/,
of the workforce, faced loyalty/security investigations as a condition of
employment. This labelling encoura
ged local police forces to harass
homosexuals by openly attacking
them in parks, clubs and bath
houses. New York, New Orleans,
Miami, San Francisco, Baltimore
and Dallas—all experienced police
raids on bars and. a large number
of arrests.
On 27 June 1969, a group of
police officers raided Stonewall Inn
a bar in the heart of Greenwich
village. The act became cause for a
riot. Thus began the Gay Power
movement, a social movement giving
SENflNAR 396 — August 1992
27
28
political visibility to the gay com- difficult. However, we can discuss India. Lakhs have migrated to the
rr unity. In time they were able to how the changing socio-economic Gulf and returned with different ex
clip away some of the institutional conditions are related to sexuality periences and rising aspirations,
structures, public policies and cul and hence make some predictions matched with a surplus income which
they could not have imagined, let
tural attitudes that sustained a sys regarding possible trends.
alone seen before. The number of
tem of oppression. In the 1970s,
women
in the working force has
Based
on
our
discussion
of
the
half the states eliminated the sodomy
statute from the penal code.. In 1974, growth of the homosexual commu also been showing an upswing, with
homosexuality was removed from nity in the US, we can identify some a declining proportion of women
t ic list of mental disorders. Several parameters which affect the nature working in household industry. In
c ties incorporated sexual preference and types of sexual interactions and urban areas, the share of non-house
into their municipal civil rights law/ the social expression of sexuality. hold industry increased from 12.9%
11 Congress, the movement found Some of these are: type of urbaniza to 14.3%. More and more women
sponsors for a federal civil fights tion, women workers, changes in were leaving their homes for work,
liiw. Thus, though homosexuals have family structure, migration, the thus acquiring greater independence
always existed in the US, for the availability of birth control, the stan in their lives.
first time they acquired political and dard of living, and the type of con
In addition, the tradition of the
sumerism and advertising.
social visibility as a rather powerful
extended joint family has broken
group.
down, giving rise to a mushrooming
TThe past few decades have seen a of nuclear families. The pressures of
Since aids is also a sexually transindustrialization and the erosion of
r pitted disease, the chances of it being
communicated in the homosexual phenomenal growth in urbanization, traditional modes of living have also
community are as high as anywhere the total urban population according led to an increase in single women,
else. Easier in fact, since in the to the 1991 Census reportedly being and it is estimated that at least 20%
West it has been established that 217 million residing in 291 citie's and of Indian households are headed by
while male to female transmission towns all over India, 23 of which women. This again means that there
occurs easily, female to male is rare, are million-plus cities. Urbanization are a large number of women who
except if the male has genital lesions has always been accompanied with live independent lives, with little
so that absorption of female sexual a break-up of close extended family male supervision.
fluids is possible. Given the higher ties and with the growth of indivi
access of males to the medical sys dualism in society. The nature of in
tem, and given the fact that it was dustrialization was also such that to Indian women have never had to
possible to identify the sub-group, a large extent, cities have had an ex fight for birth control. It has been
cess of males. In 1931, for example,
aids was initially associated with
Bombay had 554 females for 1,000 literally thrust upon us from every
gay men’s sex.
men. This was because in the early nook and corner. The government
stages of industrialization, it was advertizes condoms, abortions, steri
This history was quite unique to common for men to migrate alone lizations, pills. Even though there is
to the cities to work in factories, resistance to the forced nature of
America, and perhaps to othercoun- leaving the women and children the family planning programmes,
lriesofWesternEurope.lt did not behind in
... the
____
rural areas
.—J to tend the the overall effect is the awareness
occur in India. However, a look at small plots of land. This meant that 7 that it is now possible to separate
1 he trends in India indicates that the cities had a large number of sex from reproduction. One reason
why women prefer to get sterilized
ihere are changes taking place which single men without their families.
themselves is that if the men do so,
point to growing sexual promiscuity,
and hence a growing susceptibility
The most common living arrange and the women become pregnant,
; o all STDs, including aids. Never ment for those employed in the tex it could lead to problems. This gives
theless, it is difficult to talk about tile industry were all-male boarding us some idea of what is actually
sex in India, given the vast varieties houses. These provided a new oppor happening.
of groups that the country encom tunity for the expression of male
All this has been taking place at
passes. We still have groups practis- male sex, and for the growth in the
a
time
when there has been a rise in
ng polygamy and polyandry. There number of prostitutes. Earlier, paid
ire still areas where matrilineal sys sex was usually associated with the the living standards of a large section
tems exist, and areas where adoles other exclusively male setting, the of the people. With the help of
cent girls and boys live together in armed forces. Now, millions of unions, industrial workers, once part
hostels as part of their growing up workers were potential customers. of the oppressed poor, now earn
process. There has been so little Prostitution in industrializing cities comparatively more, so that they
work done on sexuality that to draw expanded. In Bombay, tens of thou have risen to join the ranks of the
a real picture of Indian sexuality, sands of prostitutes could be found middle class. The level of income
taking into account the many regio in the infamous cages of Kamati- earned by the middle class has also
been rising, as have the numbers of
nal and sub-group differences, is pura.
the nouveau riche. With this have
4. Savara, Mira, Changing Trends in
Besides this internal Indian migra come a growing number of consu
Women's Employment—A Case Study of the tion, there has been a phenomenal
mer durables being manufactured
Textile Industry in Bombay, Himalaya
by a large number of competing
growth
in
the
export
of
labour
from
Publishing Co., Bombay, 1988.
AIDS
industrial groups: fridges, TVs,
music systems, mixers, air condi
tioners, ovens, microwaves, con
venience foods, vacuum cleaners,
washing machines, motor cycles,
mopeds, cars. Once the exclusive
preserve of the rich, these are now
middle class household gadgets.
And all these durables are accom
panied by advertising. Erotic images,
as in the West, have become an
everyday affair. Be it the Kamasutra ad for condoms or mrf tyres,
showing the male body almost to
perfection, or be it the sensuousness
of Garden Vareili or the soft lips of
Lakme, pretty girls are used to sell
just about anything, from tractors
to computers. All these factors point
to a situation where there is a grow
ing tendency towards freer social
relationships outside of immediate
family, village or caste control. With
the increasing independence of
women, one would expect a larger
number of affairs contracted, not
on the basis of force or money, but
for mutual satisfaction. Prostitution
would possibly grow in new areas,
and specially in large towns where
the first generation of villagers are
leaving the confines of tradition.
We could also expect a more open
form of homosexuality.
Inhere are some indications affirm
ing the growth of a more open form
of sexuality. The number of cases
coming to the government sto
clinics, which only records the tip
of the iceberg, is increasing: from
479,000 in 1978-79 to 919,000 in
1984-85. The number of abortions
done in government clinics has also
risen from 317,000 in 1978-79 to
573,000 in 1984-85.5 Last year,
Bombay Dost, the first magazine
devoted exclusively to those practis
ing an alternative sexuality, was
launched.
Studies on sexual behaviour pat
terns would give us an idea of these
changing trends. Unfortunately, in
India, there has been no study of
actual behaviour patterns, of what
■people actually do, as opposed to
what people think people should be
doing. It has long been assumed that
virginity and monogamy were the
5. Department of Social Welfare, Hand
book of Social Welfare Statistics^ Governof India, 1986.
general rule. Deviant forms, like
hijras, existed, but they were on the
fringes—little noticed, of little con
cern.
lR.ecently, however, a magazine
conducted a small survey on the
actual behaviour patterns of urban,
educated men. The sample consisted
of 1500 men, and the results broke
several myths about the nature of
Indian sexual behaviour.6 Over fourfifths of the men had had sexual
intercourse, 41% of them before
they had reached the age of 20. Only
22% had their first sexual experience
with their wives; 29% had it with a
friend, 21% with a paid person. 13%
had their first experience with a
relative, while for 10%, it was with
a person of the same sex.
Among married men, 55% claimed
to have had extra-marital affairs
with a non-paid person of the oppo
site sex. 25% of these affairs took
place with relatives, 18% occurred in
the workplace, and 53% with
friends. Thirty-seven per cent (414
men) claimed to have had homo
sexual experience. It was usually
at a young age, 80% having had
it before they were 20. 220 of
these men were married, and a third
of them said their wives knew about
their homosexual activities. A fifth
of the men said they had had over
10 persons. The main reasons given
by respondents (30%) who claimed
to have gone in for paid sex were
because they felt like it, and because
they were on tour. Of them, 43%
had been to 1 to 5 women, 23% to
over 10. Only 19% of this highly edu
cated group used a condom on such
occasions. Anal intercourse, con
sidered by many to be the act of
homosexuals, is not so. Among the
married men, 20% said that they had
had anal intercourse with their
wives.
This is a small sample, based on a
self-administered questionnaire pub
lished in an English magazine. It
points to the urgent necessity of car
rying out more extended research on
sexual behaviour patterns. However,
this small survey indicates that there
is much sexual activity going on
6. Savara, Mira and C.R. Sridhar,
‘Sexual Behaviour of Urban. Educated
Indian Men: Results of a Survey’, Journal
of Family Welfare. Bombay, April J 992.
outside marriage, which is not con
fined to prostitutes or paid sex.
The current emphasis of ajds edu
cation work has been on the prostititutes, with free and subsidized
condoms being distributed and then
being ‘motivated’ to educate their
customers to use them. Here, it is
crucial to understand the basis on
which the exchange between prosti
tute and client occurs, and to what
extent she is capable of negotiating
the terms of that exchange. This de
termines whether she has any barga
ining power over the usage of the
condom. In India, supply far out
strips demand, and in many cases
women are totally dependent on only
sexual exchange to make their live
lihood. In such a situation, it is
unlikely that she would insist on
condom usage.
Increased
bargaining power is a
precondition for the prostitute to be
able to negotiate the terms of her
contract. In the absence of this, all
propaganda, like free condoms, get
thrown in the garbage. Not eating
today is far more real than the possi
bility of getting a disease from an
act which she has been performing
for years, without too serious a prob
lem. For an Al DS^in tervent ion to
make sense, it needs to be linked
with empowerment, which can only
occur if other means of making an
income exist, aids education for
prostitutes'has to be linked with in
come generation.
But prostitutes, as a distinct group,
are not the only ones concerned with
sex. As the survey indicates, a rela
tively high number of affairs are with
relatives and with co-workers. In the
absence of data, it is difficult to con
clude that these are totally volun
tary. Since there is an unequal social
relation, it is possible that women
in such a situation have little.control
over the conditions of sexual ex
change. The focus.dn usage of con
doms with prostitutes denies the need
for clients to use condoms in their
other sexual encounters.
As the above statistics show, the
extent and nature of sexual contacts
is far wider and the range encompas
sed similar to the other social con
tacts a person is likely to have.
Hence, the emphasis on educating
seminar 396 — August 1992
29
prostitutes about aids creates the
illusion that it is a disease which is
primarily transmitted by this group.
l-Jittle of the educational work
addresses itself to homosexuals. This
is because at some level there is
denial that homosexuality exists here,
particularly since its social expres
sion differs from that in the West. In
India, homosexuality is not percei
ved as providing an exclusive
social identity. However, the survey
mentioned earlier does indicate the
prevalence of such behaviour, altho
ugh most men do not engage exclus vely in- male-male sex. Hence the
social matrix of the possibilities of
aids transmission in India differs
substantially from the West. And it
is evident that if the current focus
On prostitutes continues, it will fail
to contain the infection. There have been some attempts to
educate the public through ads and
tv. The lesson giost often given is
that aids is a killer disease. The
picture of a skull with aids written
bver it has become commonplace. It
carries the message that sex could
equal death, a message which would
probably jibe weH with the West,
given its Christian sub-culture that
sex equals sin. However, the usual
understanding is that the Indian
conception of sex is quite different.
Our myths talk of creation as a
joyous act of intercourse: our gods
are always male and female together;
control of sexual energy can be a
means of spiritual enlightenment in
Tantra: the erotic sculptures, or
what remains of them after all the
invasions and breaking of temples,
are one indication.
30
The current educational camp
aigns on aids treats sex in the ab
stract manner of the West.
go with another woman....you could
get aids.’ The ads for Kamasutra
condoms show a much better under
standing of the Indian feeling for
sexuality, including it as part of the
skill in making love. The view of sex
as dehumanized and impersonal, as
something which could cause death
is currently being supported by a
multi-dollar campaign funded pri
marily by the West. Local NGOs
working on aids have been drawing
attention to the West’s ideological
control of the way we approach our
problems. For example, already the
World Bank has stipulated that the
aids project must be run by an inde
pendent body, outside government
control and with free access to who,
which will monitor and evaluate the
project.
Local NGOs also allege that the
national aids project is being hijack
ed by foreigners and India could
soon become'a playground for for
eign aids researchers, just as Africa
was in the 1980s. This is a real
possibility, given the fact that the
international aids programme has
reached the stage where they want
to test possible cures.7
In the West, there has been a
growing separation of sex from other
kinds of relationships. The advice
contained in sex manuals seems to
be directed towards machines, to be
I touched here, tickled there. Com
pare it to the Kamasutra, which laid
down complicated ethics of behavi
our and gave hints on how to app
roach others’ wives and courtesans.
Romancing, and the art of seduc
tion, of pleasing the other, is what
is important. Sensuousness. Not this
obsessional preoccupation with the
orgasm. It is a more total experi
ence, entwined into the texture of
life, with smell, taste and feeling.
AIDS
The current aids campaign is based
on an understanding of sex, indivi
duals and society which has essen
tially come from the West. Sex is
referred to entirely in the abstract,
as an act which exists apart from
the individuals concerned: a medicotechnological impersonal act, to
which we have to apply our scienti
fic, men as object, gaze. The pur
pose of this article has been to
indicate that sexuality is a social
construct, and that its construction
in India differs from that of the
West. Our current educational cam
paigns are based on a lack of infor
mation, or information that we are
incorrectly transposing from the
West. And this has serious implica
tions. Finally, it is only with an
open recognition of the need to
understand' sexuality and disease
within our own culture that any
adequate and effective educational
campaign can be developed.
7. ‘IBRD Funding of aids Project
Flayed’, Economic Times, 8 April 1992.
Hapless victims
S.
SUNDARARAMAN,
SURESH
PURUSHOTHAMAN
THE Human Immunodeficiency
Virus (hiv) first made its official
appearance in India in Madras in
1986. The first few cases of mv
infection were reported amongst
women engaged in prostitution (pros
titutes are hereinafter referred to as
the CSWs or commercial sex wor
kers). Not surprisingly, a great deal
of frenzy was whipped up in the
media and the popular feeling was
that if you do away with these
women, you’ve killed the problem.
This is not being realistic even if
prostitution provides an imminent
threat of transmitting the virus. A
whole gamut of issues need to be
looked Tmo for us to develop a more
understanding and mature outlook
towards those segments of societies
which are sought to be marginalized
further as a result of this epidemic,
and overall, towards the very import
and
A. K.
GANESH
of hiv and’aids in our society. This
article attempts to explore a few
of these. It should be noted, how
ever, that the scope of the article
confines itself to the women operat
ing in the lower socio-economic cate
gory and does not apply to those
operating in higher economic levels.
The CSWs are predominantly
from the economically weaker sec
tions and operate from diverse
locales like rail/bus stations, cinema
theatres, other public places and
highways. Their lower levels of
income per sexual encounter necessi
tates them to have the maximum
number of clients possible within
the day. The high number of sexual
contacts increases their risk of con
tracting hiv from an infected part
ner. Consequently, this large client
turnover, intrinsic to sex work, also
magnifies the risk of infection from
seminar 396 — August
1992
31
Hiv through clients who are already
him infected.
CSWs though, are not the only
dimension to the whole problem.
The clients of these sex workers, who
belong to all sections of society, have
a greater chance of transmitting the
virus across the general community.
The social and cultural factors that
govern our societies respond in a
malnner that is at variance with this
reality.. Marginalization of the sex
workers under the premise that they
are the real and only vectors of
transmission is taking place, and
the chances of orchestrating detec
tion to fix the blame on them there
fore become higher, all the while
clients being the unseen partners of
hiv transmission.
T
i
JL he problem of hiv and the
vulnerability of the commercial sex
wqrkers to its transmission is further
compounded by several factors that
have hindered the prospects of their
being able to lead a healthy and full
lift.
*
A majority of the sex workers are
illiterate. This renders preventive
education campaigns in the media
hai’d to reach this community. Out
reach based, community level inter
vention strategies are the only viable
an^i credible option.
Because of the high turnover of
clients they have to ensure to meet
their economic needs, and because
of the fact that both medical treat
ment and the time spent on it cons
trains their earning a great deal,
CSWs accord health the lowest pri
ority. Their genital hygiene being
poor, they are subject to repeated
vaginal trauma. As is the case in
even the general population, any
occurrence of Sexually Transmitted
Diseases (STDs) is often neglected
and left untreated. Since the danger
of Hiv transmission is much higher
in the event of an std, the sex wor
kers are at greater exposure to the
virus.
32
Protective devices i.e. condoms
are rarely used within the ambit of
coijnmercial sex. Many workers har
dly possess the knowledge nor do
they have access to the information
that use of condoms minimizes risk
of transmission. Granting that hiv/
aids prevention and education camAIDS
paigns do offer a credible and cor
rect source of information to the
sex workers, what are the factors
that deter assimilation of this infor
mation and subsequent shift to pro
tective sexual behaviour based on
this knowledge?
1 rsiditionally,
since
the
man
woman relationship in our country
has always been loaded in favour of
the male, women are often always
left without any decision-making
powers. Both within the confines of
a family, a marital relationship or
outside of it, men have always had
their say in all matters. This socio
cultural factor extends itself to com
mercial sex work as well.
Women sex workers, faced as they
are with competition and economic
pressures, are left with very few
options to enforce or ensure condom
use. This feeling of absolute power
lessness negates any positive effect
that hiv/aids education or know
ledge aimed at the commercial sex
workers would otherwise have.
Clearly, the pattern of hiv trans
mission across the country is hetero
sexual, multi-partner sex. The taboo
that clouds and inhibits open dis
cussion of sex and sexuality in India
constricts any reasonable knowledge
of the magnitude of sexual inter
action that takes place outside of
commercial sex. It, therefore, be
comes all the more easier to fix the
blame for spreading hiv on the
CSWs, which is grossly unfair.
Moreover, in view of the lack of
any policy framework for the testing
and surveillance of hiv, forcible test
ing of the CSWs and thus coercive
detection of infection among these
women leads to a more greater dis
tancing of the problem. The popular
perception that the sex workers are
responsible for infecting others, igno
ring the fact that clients infected
them in the first place, has led to
all strategies centering around this
community. Reality demands other
wise.
Like the rest of the world, the
Indian government also initially
adopted a cavalier attitude towards
hiv/aids. The epidemic was sought
to be controlled by merely margina
lizing and isolating the commercial
sex workers. With each passing day,
with more and more cases of infec
tion being reported from amongst
the general population, the centre
awoke to the haunting reality that
here was something that necessitated
more than disease control measures.
Yet, precious little has been done
apart from drawing up elaborate
plans and strategies. The time lost
in the implementation of these, how
ever myopic they may be, is proving
to be costly. Information and edu
cation campaigns focusing on pre
vention have still not been taken up
by the government, aids, however, is
high on the priority list, even found
to be deserving the formulation of a
medium-term plan.
Few state governments, notably,
Maharashtra, Manipur and Tamilnadu, have initiated any action.
These states are then considered to
be epicentres of hiv infection in
India. The thrust of these strategies
is predominantly on minimizing Hiv
spread, with not much being done
about std prevention which could
hold one of the keys to the success
ful combatting of the epidemic.
India boasts of an extensive net
work of non-government, commu
nity-based organizations that are
dedicated to serving society on so
cial, economic and health/medical
fronts. NGOs working exclusively
on aids have been few and far.
However, many other grassroot
organizations have now started to
concentrate their energies on hiv pre
vention.
The major stumbling block for
NGOs working on aids seems to be
the acute sensitivity attached to dis
cussing issues relating to sex. Many
of the NGOs themselves are not
comfortable while talking about
these issues and STDs, as also in
working with or among the CSWs.
Quite a few have adopted retro
grade, regressive policies with a re
formist stance aimed at the abolition
of the practice of prostitution. The
ground reality that it will take a
social and economic revolution to
end this profession, which is un
foreseeable even in the long-term
future, has escaped these NGOs and
they work at cross-purposes to the
whole effort.
However, there have been a few
interventions aimed at sex workers
that have adopted a more humane,
non-judgemental approach to the
whole issue of prostitution and hiv/
aids. Notable among them are the
Indian Health Organization; Popu
lation Services International; and
the Bombay Municipal Corporation,
all of whom work in the red light
district of Kamatipura in Bombay.
As is apparent, much of the focus
and effort has been concentrated in
one geographic area i.e. Bombay,
where a modest measure of success
has been documented.
TThe need of the hour is therefore
to look at successful projects and
adopt these to suit the socio-cultural
needs of particular geographic areas,
and quickly and efficiently replicate
successful projects/programmes ad
dressing std/hiv .transmission thro
ughout the country.
As discussed earlier, a shift in
focus from interventions aimed to
ward the commercial sex workers to
the clients, is imperative. During the
course of a one-year pilot project
conducted among the commercial
sex workers by the aids Research
Foundation of India in Madras,
• several observations were made,
which have been discussed earlier:
absolute lack of information/knowledge on hiv/aids due to illiteracy,
lack of negotiating skills and power
to enforce/ensure condom use etce
tera among the CSWs.
It was then decided that it was
futile to aim all interventions at the
CSWs alone, without creating an
environment that is conducive to the
adoption of prevention mechanisms
while selling sex. More gains would
follow by shifting the focus of inter
ventions to the clients of these sex
workers. Since the presence of STDs
is a fairly good parameter of the
vulnerability to hiv infection, a
study was done at three std clinics
in Madras city which revealed dis
tinct profiles of people reporting
infections. Correlated with the in
formation culled from the CSWs
about client patterns, these were
seen essentially as people who were
migrant or living outside of their
home towns/villages. Few of the
client profiles were of long-distance
truck drivers and other transport
drivers, blue collar industrial wor
kers, construction workers, port
employees etcetera.
The clients came from diverse
segments of society and as such, ex
hibited diverse socio-cultural behavi
our that was peculiar to their indivi
dual communities. For example, it
was found that the long-distance
truck drivers were familiar with
condoms on a day-to-day level,
though for a different purpose: they
used it to plug radiator leaks.
Their constant sex seeking was born
out of a felt notion that they had to
dispel the heat assimilated in their
body due to being exposed to the
engine heat during their long jour
neys. This notion was passed down
among their community by genera
tions of truckers.
It was also observed that the con
struction workers took to commercial
sex seeking due to the fact that they
were mostly migrants living away
from their families, and that the
port employees patronized CSWs
mostly on Fridays, their weekly pay
day. Such factors need to be care
fully analyzed and used to develop
and implement interventions that
are appropriate to the different
segments of the people involved.
In the light of the current projec
tions of hiv infection that portray
a very grim picture for the coming
years, hiv control programmes have
to immediately assume a much more
broad-based canvas that ensures
that prevention messages reach
everybody and consented safe sexual
practices become the norm of the
day. The immediate need for inte
grating std prevention with the hiv
prevention programme should also
be addressed.
The CSWs do require particular
attention due to their specific vulner
ability to the infection. But, before
interventions repeatedly target these
people, an atmosphere that is con
ducive to their negotiating and sell
ing safe sex must be fostered. It is
for this reason that the focus now
needs to be shifted towards the
clients and that a positive change
from unsafe sexual behaviour to sate
sexual behaviour that promotes a
bi-directional process is brought
about within them.
SEMINAR 396 — August 1992
33
Puttie PsMey
CHAPTER
Vohm^rv Health Association of Mio
21
INFERTILITY AND PREGNANCY LOS^
llewritlen by
JILL RAKUSEN
NFERTILITY
nfcrtility is a life crisis. It is usually unexpected; often we
don’t know how to cope with the feelings raised by the
experience of discovering we arc infertile. There is an
initial reaction of shock and denial.
(
I, like every other woman in this society, always
believed that I would have children without any
problems - as many as I wished, and when I
decided it was the right time. Unfortunately, after
four years of trial and error, tests, operations,
etcetera, my husband and I are realizing that life
does not always happen the way we plan it. I have
found it quite hard dealing not only with our
infertility problem but also with the reactions of
people around me.
I'm sick of people telling me to ‘relax', ‘stop
thinking about it', ‘adopt and you’ll get pregnant',
and all the other wonderful cliches that, although
said to be comforting, ring of insensitivity. Friends
and family can never possibly know the pain that I
feel inside, the anger and ^resentment 1 feel every
time I see a woman walking down the street with a
big belly. How could they understand? How could
anyone capable of having children understand?
Often you find yourself putting off making decisions, or
changes, because ‘six months from now you will be
pregnant*.
I slopped teaching five years ago to become
^pregnant. When that did not happen, everyone
wanted to know what i could possibly be doing at
home all day if I didn't have kids. Neither a
mother nor a career woman, I stayed in limbo
because I kept thinking, Maybe it will happen this
nionthl I was drifting, and it is hard to believe so
much time has gone by with just this single
'purpose in mind.
When women you know have children, it may be hard
for you to relate to them. I'cclings of envy, jealousy and
‘why them and not me?’ are common. Because holidays arc
so child-centred, they can become slicssful, lonely and
depressing limes for you. You may feel isolated from friends
or your partner.
t
•
My husband is disappointed with our failure to
conceive, but he could easily accept a child-free
life. He says he understands my feelings and
sympathizes, but doesn’t care to hear any more
about the subject. His view is ‘Flay the cards dealt
you - you go on about your business no matter
what. His disappointment is mitigated by
involvement in a job he likes and other
alternatives. I have not found a satisfactory
alternative.
Infcililily is not only a problem for childless women.
Difficulty in conceiving a second or subsequent baby is uol
uncommon.
I didn't feel I had the same right to grieve as a
woman who had no children. Yet the loss seemed
particularly intense because I knew what it was
that I was losing. I was being denied the pleasure
of holding my own baby in my arms again. I could
feel what it felt like but I couldn't have it. All 1
had learned about mothering would be wasted. For
fifteen months my life seemed to have been
suspended while I waited to fill the hole inside me.
Anger is a common feeling, but it is hard to know where
and towards whom to direct it. We tend to look for a reason
for our infertility. We may feel that something we did in the
past caused our present inability to conceive. Some people
irrationally think that masturbation, unusual sex practices,
etc., have caused this form of‘punishment’. They do not
cause infertility, but our mindscan trick us into believing it
and make us feel terribly guilty. Or we may feel that wcarc
• ' • .. I
INFERTILITY AND PREGNANCY LOSS 423
’
to blaihe because we had an abortion. As we discuss in the
abortion chapter, while abortion can result in infertility,
this is very rare, unless the abortion was badly performed or
wash7fcaMul)y followed up.
Depression, sadness and despair arc common.
'
"
■
Ji
:
I grew up surrounded by the idea that if you were
willing to work or study hard and always did your
best, nothing was beyond your grasp.Oerttfatly I
have found this to be true. The theory fell apart
when I began to deal with my infertility problems.
Not only did I become very depressed, but without
the help of a friend of thine who shares the same
problem I seriously doubt whether my marriage
would have remained intact.
It is only through a great deal of pain and anguish
that I have begun to accept the idea that I may
never have children. After the initial shock wore
off, my husband and I became closer than ever.
I wish that more doctors dealing with infertility
would address themselves to the feelings of their
patients instead of leaving them floundering,
■ looking for their own resources.
Pm tired, I’m tired of an empty, longing, aching
heart that yearns to hold a little baby of my own.
Oh, I’ve tried everything. I’ve tried praying,
relaxing, furthering my education, working hard at
my career, social clubs, church work, service work,
slimnastics, cross-stitch - you name it, I've tried it.
Andi still cannot get rid of that aching, yearning,
longing emptiness that can only be known by
barren women.
Infertility is defined by most doctors as the inability to
conceive after a year or more of sexual intercourse without
contraception. I’hc category includes women who con
ceive but can’t maintain a pregnancy long enough tor the
fetus to become viable (able to live outside the mother).
You have the right to seek help or advice whenever you
begin to feel conceiiicd about your failure to become
pregnant. Infertility may be a temporary or permanent
state, depending on your problem and on the available
Irgatincnts.; Many people arc surprised Io learn that
iiilcitilily is not mmsual. Coiimionly (piotcd hgmes aie
that between 15 and 20 per cent of couples arc intcrlilc,
although there are no reliable data on the subject (sec
Pfeffer and Quick in Resources).
CAUSES OF INFERTILITY
Fertility involves complex physiological events, some of
which arc poorly understood.
Male infertility may be connected with:
I. Piohlcms of production .ind malunilion of sperm,
c'g. because ot previous mlcclioii, such as mumps;
undcscendcd testicles; environmental factors (including
chemicals in the woikplacc and drugs - both picsciiplinn
and otherwise).* Extremely intensive exercise
c.g.
marathon running - has been (mind to lower sperm count
too; infertility has Been recorded in some male Olympic
marathon runners according to Professor Rose Frisch pf
Harvard Medical School. The effect is reversed when
exercise is reduced.
2. Problems with sperm movement (‘motility’) - but little
is known about what causes this.
3. Blocked tubes through which the spejm travel, poss
ibly caused by untreated infections. (Vasectomy Evolves
blocking these tubes deliberately.) Varicoceles (swelling of
the veins from the testis) may also affect some men’s
fertility.1
4. Inability to deposit sperm sufficiently near the cervix,
because of disability, impotence, premature ejaculation or
malformation of the penis (e.g. when the opening is either
on the top or underside of the penis instead of the tip).
5. Poor nutrition and poor general health. See Diet
p. 425.
6. It is possible that psychosomatic causes may also play a
part (see p. 425).
Female infertility may be connected with:
1. Hormone problems: failure to ovulate regularly or
irregular menstrual periods may be due to a problem in the
ovaries, pituitary, hypothalamus, thyroid 01 adrenal
glands, or to the normal ageing process - as we .ipproach
menopause (see p. 454), we ovulate less frequently.
Women often develop amenorrhoea (absence of periods)
following use of the Pill or Dcpo Provera (DP). While there
is as yet no clear evidence that Pill-use can result in
permanent infertility, it can certainly cause infertility for
many, many months and for several years in women who
are in their thirties and have never had a baby. Prolonged
Pill-use seems to increase this risk in older women. Women
who have irregular periods or who are older when they
begin menstruating also seem to be more prone to this 'post
Pill syndrome’.2 We do not know enough about DP to be
specific about its effect on fertility. Sometimes fertilization
does occur but low progesterone levels may mean that
implantation docs not occur, or the pregnancy is lost in the
first twelve weeks.
2. Scarring on tubes or ovaries from endometriosis (see
p. 485) or unhealed infection due to STD (sec p. 503),
gynaecological procedures such as a D&fC or abortion, or
•SeeChapter 9. p. 151 for certain environmental factor:.; for information about
drugs known to affect the male reproductive system, see Out of Our Hands by
)ill Rakusen and Nick Davidson.
•Schwartz ct al found that older women lend Io take a hllle lom-i i Io get
pregnant than younger women ’ Although they did not establish w hat propor
tion. if any, of women over thirty-fise failed to get pregnant at all, this study has
Ix-cn widely referred Io as indicating that women should get pregnant in their
twenties or face infertility. Iliis is not only groundless on the basis of the
es id. n« v i ilcd. il ah. fails In lake into at < ••mil the ni galivc < ff« i h <d having a
, luidtail) s«« I"' ‘ sample I >.mii I* and Wi mgai leu, wlmhiimd that, wllhmil
cxcqilioii. couples who had then fust child in their early twenties later wished
they had delayed paicnlliood until they had dcvclo|<d as individuals and as a
|uiilii«*ishi|) 4
424 CHILDBEARING
the use of an IUD (see p. 287). Even infection following
childbirth can cause infertility.
3. Abdominal surgery: it is possible that some medical
emergencies in childhood, in particular a perforated
appendix, could be responsible for subsequent infertility,
particularly if the emergency was not treated with this in
mind But there is more evidence that poorly conducted
abdominal surgery (c.g. that is rough or unnecessarily
damaging) is a Cause. Dr Robert Winston, whose research
has highlighted this problem, has found that a considerable
proportion of infertility cases he sees are iatrogenic (i.e.
caused by medical treatment). See Out of Our Hands for
further discussion.
4. A badly done abortion, or as a result of an untreated
infection after abortion (see Chapter 17). Abortion is widely
believed to be a cause of infertility; while this was indeed the
case when abortion was illegal, the risk of infertility with a
legal abortion, particularly early abortion, is minimal, and
with late abortion the risk is mainly due to cervical damage
if the doctor is not careful.
5. Structural problems in the uterus, due to congenital
problems or exposure to certain drugs such as DES and
other hormones while being carried in their mothers’
Womb, can cause infertility in some women (by preventing
conception or affecting the ability of the uterus to sustain a
pregnancy).
6. Other factors, such as genetic abnormalities, fibroids,
extreme weight loss or weight gain, excessive exercise (see
Chapter 6), poor nutrition, stress and chemicals at work or
in the environment at large may affect a woman’s fertility
(see Chapter 9). So, too, may subconscious feelings of fear
or anger (see p. 425).
A couple may have a combination of problems which
results in infertility. Eor example:
1. Sperm being unable to penetrate the cervical mucus;
this problem tends to be defined solely as the woman s
problem - the woman having ‘hostile mucus (which may
be due to an infection like chlamydia or T mycoplasma the treatment of which can often result in pregnancy).
However, as Hull et al. conclude: ‘The usual terms “cervi
cal infertility” and “mucus hostility” are . . . inappropri
ate’, except In unusual circumstances. They found that
‘defective sperm function’ is a frequent hidden cause of socalled hostile mucus.5
2. They may not know when the woman is fertile, how
often to have intercourse during this time or what to do to
mgke pregnancy more likely (see Self-help below).
It is thought that the causes of infertility arc roughly equally
divided between male factors, female factors and joint
factors. However, in around 10 per cent of cases, it is not
always, possible as yet to diagnose the cause of infertility;
when the cause is not understood (which may sometimes be
because of inappropriate sequencing of tests) it is referred to
as 'idiopathic infertility’. We must press for more research
about the causes and prevention of infertility, and for
re.ignition and application of future and existing know-
ledge. In particular, the effect of ’environmental' actors on
both sexes’ fertility, including stress, drugs, chemicals
present in the working or home environment, or
<......in the
environment at large, is largely unknown, but all'I are
(sue Out of
thought to be relevant, at least to some extent
c
Our Hands). We do know about certain drugs (e g. peopfle
of both sexes who as fetuses were exposed to i) sS in the
womb have an increased risk of fertility problems) and this
can teach us lessons about other (hugs and c icmicals.
many of which arc used with little thought about ong-tenn
effects. Effects on fertility, for example, can take nore than
generation to
to snow
show up,
up, um
but muy
they’■>ll only show up........
at all- -if
one generation
they are looked for, and Io do that accurate records must be
kept and the will to look at them must exist.
SELF-HELP
Learning about Our Fertility
This can help a lot. Masters and Johnson stated that one out
of five couples who attended their infertility clinic: over a
within
three
twcnty-four-ycar period conceived v.
. .............
- inonlhs
with no treatment other than use of this basic information:
if your menstrual cycle is regular, whether it ’ x?! long or
short, you will probably ovulate fourteen days (giv<-e or take
twenty-four hours cither way) before the beginn ng of your
next period. In other words, you should try lo become
pregnant on the thirteenth, fourteenth and fifteenth days
before your next period. During these three days, spacing
your love-making is important (sec Fertility Awircncss » P•'
37). A man’s sperm production decreases if he nakes love
too often, so you should have intercourse no more than
every thirty or thirty-six hours to keep active sperm in
once (—j
,
• ’ ofr time, Infertility
your genital tract during that period
clinics suggest a four- or five-day abstention period in
order to get a high sperm count.
Use no artificial lubiicant when having intcicoursc and
never douche afterwards. If lubrication is necessary, saliva
is the safest choice. Your partner’s penis should remain
inside you until it has gone limp. Approximately 60 to 70
per cent of the sperm are contained in the first part of the
ejaculate. Since it usually takes about twenty minutes for
sperm to reach the uterus and fallopian tubes, iti is a good
idea to lie on your back with your knees elevated for about
thirty minutes.* If your uterus is not tilted jack,
i. ' . your
,
chances of conception may Ik increased by having iiikryour partner alxyve and facing you, and a folded
coursewith
'
pillow under your hips to raise them.
You can.1 «also get a good indication of whether or when
you arc ov/ulating by using a basal temperature chart, and
monitoring the type and amount of your cervical mucus
(see I'crtility Awareness, p. ^7 for how Iodo this). > on cun
then time intercourse Io coincide with your fcitilc time.
Planned sex can reallv affect your sexual life. You have to
it becomes
plan intercourse around your menstrual cycle, i.
--------•Some women recommend doiiching * ith baking mxI.i thirty ininiilcs More
intercourse to change the . ..nsistency of cervical mucus a id make it less
viscous, so that sperm encounter less resistance.
u
INFERTILITY AND PREGNANCY LOSS 425
less an act of loving and pleasure and more a medically
necessary response. Recording the times of your inter
course on a temperature chart may make you feel that
nothing is private or sacred in your life any morel
441) recommends a specific diet along the lines su;,.- »kd
above, as well as other naturopathic ideas.
Women who are underweight may also find th.it weight
gain increases their chances of conceiving.9 In addition, it
has been suggested that deficiency in ‘essential fatly acids'
I started with the temperature charts. This was
quite taxing for me, and menially depressing. I felt
very regulated and calculating, both with my own
body and in my relationship with my husband. 1
need not say what it did to our natural sexual
impulses. But a child at all cost - this was how we
felt. My husband woke me every morning at six
a.m. so that 1 could lake my temperature.
Afterwards he charted it. I needed his involvement.
can lead to infertility, especially in men. As lllcij name
suggests, these fatty acids are essential nutrients. For infor
mation about them, sec Chapter 4. Some researchers also
recommend that men with infertility problenv* increase
their intake of zinc, Vitamin C and Vitamin E, as reported
by the Boston Women’s Health Book Collective. T here is
certainly evidence of male cases of subfertility responding
to zinc supplementation.10 At the very least, men? like
women, should pay careful attention to their diet.
'Social' Drugs
Learning about Ourselves
There is some evidence that subconscious feelings - e.g.
If we take "social’ drugs, wc can try cutting down on Jhese,
fear, at some level, of having a child - may be responsible
for infertility. Dr Paul Entwistle has had considerable
or eliminating them altogether. Drink? containing caffeine
success in enabling such feelings to surface and be resolved
through hypnosis - with ensuing pregnancies6 - and it is
possible that therapy, self-therapy or co-counsclling (sec
Chapter 8) may be helpful in this area, as well as hypnosis.
Learning Relaxation and Similar Techniques
are associated with decreased fertility. Alcdhol and tobacco
are potentially harmful to sperm production, as is heavy use
of cannabis, which also seems to be associated with irregu
lar ovulation in women. Smoking in women decreases
fertility - the greater number of cigarettes smoked, the
greater appears to be the irk.11 (Ex-smokers do not appear
The link between stress and infertility in women with no
‘structural’ reasons for their infertility may sometimes be
to be unduly at risk from infertility problems.) Heavy
alcohol consumption may also impair fertility in women,
although the evidence is mixed. (For more about drugs, see
due to increased prolactin secretion.
Chapter 5.)
Although little
research lias been done on this, there is evidence to suggest
that reducing prolactin levels by reducing stress-alone may
indeed help such women get pregnant, or doing this in
SEEKING MEDICAL HELP
combination with hormone drugs where appropriate (see p.
Ideally, ask your GP to refer you to a clinic which spe
428).* Of course, the whole process of trying to get
cializes in infertility and where the same doctor sees both
pregnant can be extremely stressful. Anything you and your
partner can do at this time to find ways of experiencing
inner peace and calm on a regular basis is likely to be
helpful generally; it will help you cope with the pain and
you and your partner. Many family planning clinics run
infertility sessions; you can refer yourself to these. You
turmoil, and may even increase your chances of getting
always offer help to ail women; sometimes, for example,
they will only sec married women. If you feel obliged to go
usually have to wait for an appointment at a fertility clinic but it should not be more than three months. Clinics do not
pregnant. Self-healing techniques such as visualization may
also help. See Chapter 7 for further information.
outside the NHS, bear in mind that private treatment does
Diet
not mean better treatment, but it may mean getting help
more quickly.
The charitable,
non-profit-making
Poor diet contributes to your stress too. T here is also
evidence that women who live on refined foods appear to
.secrete smaller quantities of the hormone responsible for
ovulation than women who have a diet rich in unrefined
cereals and fresh vegetables.8 Indeed, a naturopathic
organization BPAS (sec p. 442) is a good bet for single or
lesbian women, and in general provides a mode) service,
which the NHS would do well to emulate. For more on
where to go for help, see Pfeffer and Woollett, and Pfeffer
and Quick, listed in Resources.
approach has reportedly been successful. T his approach
Since, overall, the causes of infertility arc equally dis
assumes, for example, that the vaginal secretions can be
affected by diet, and if the secretions arc too acid, sperm can
be destroyed. To ensure alkaline secretions, wc need to cat
tributed between women and men, it is obvious that in any
couple the man and the woman should be diagnosed and
treated together. If the man has the problem, then testsand
a lot of vegetables (preferably raw) and fruit. Alkaline
pessaries or solutions can also be used, if you have a
treatment involving the woman alone have no value. A
man, because of his anatomy, is easier to diagnose: semen
analysis is one of the logical tests to perform first.
constant, heavy discharge (leucorrhoca), diet can also deal
with this. Kelso’s Women's Ailments (see Resources, p.
* In an as ycl unpubiislivd paper, Klona and Roiy O'Mooic of Didtlin studied
thiilcen infertile couples who were taught autogenic training - a fomi of
iclaxatiou. It reduced prolactin levels and ‘anxiety scores’, and three of the
won a it got picgn.ml
•............
Everyone seeking help for infertility needs support fmiii partners (il wc have them), close friends, family or an
infertility support group. The experience of infertility can
be very isolating. Ifatall possible, lake someone with you to
ymii appoiiiliiieiils.
public policy DMta
Voluntary Health Association of Indi.
426 CHILDBEARING
DIAGNOSIS
Br tish clinics vary a lot in the type and quality of diagnostic
tests they do. In some clinics the man is not even examined.
This is an unacceptable way to investigate infertility. Make
sure that both of you are examined and that full medical
histories are taken.*
Though a sequence of diagnostic studies will vary with
both doctors and individuals, it should include the
fo lowing:
1. A general physical examination and medical history of
bdth man and woman.
2. A pelvic examination of the woman. Your reproduc
tive tract, breasts and general development will be checked
for hormone balance. Tell your doctor about your
menstrual history, its onset and pattern; about any previous
pregnancies, STD episodes or abdominal operations, about
ycur birth control history; about your sexual relations (c.g.
frequency of sexual intercourse); about where you live and
w lat contact you and your partner have (had) with chemi
cals, and about drugs either of you arc taking.
3. A basal temperature chart. You may be instructed in
the use of a special thermometer and chart, and taught how
tq record your temperature to see if and when you are
ovulating (see Self-help above).
4. Semen analysis. Your partner ejaculates a sample of
semen into a clean container. It must be kept at body
temperature and examined as soon as possible under a
microscope to determine the sperm count and motility. A
count over 20 million sperm per cc is considered in the
normal range; below 10 million per cc is considered poor.
Yet doctors disagree about how to assess fertile sperm and
men with low sperm counts can impregnate. If the sperm
count is zero the man will be examined for blockage in his
tube.
’ ,
Ask to repeat the semen analysis at least one more time,
the test is notoriously unreliable, not least because of
ignorance in some clinics, and a man s sperm can fluctuate
ih count and motility for many reasons, including stress,
if thpscmen analysis continues to be worrying, your partner
s iould pursue his own diagnosis and self-help strategy (sec
a rove) before you have further tests, t
Any diagnosis of infertility can make things difficult for
both man and woman.
■ i
My husband’s sperm count was very low; we were
both crushed. I don’t think my husband believed it
was actually happening. In fact, he often talked in
the third person, not truly accepting the results. I
didn’t know what to say. I couldn’t say the typical
'Oh, it’s all right’ because we both knew it really
wasn't all right. Bor some reason, I found I could
handle a problem with mysell but lound it very
difficult to handle my reaction to his problem. I
was even more concerned that he couldn't handle
his problem.
5. Blood levels of the hormones oestrogen, progesterone
and prolactin as well as urine tests to determine your
hormone levels and whether ovulation has occurred. I lormonc tests arc also done following treatment with certain
drugs (see p. 428).
6. STD tests, particularly for chlamydia, which can
cause infertility in both men and women. Make sure you
both arc tested for this (you may have to go to an S 11)
clinic, see p. 488).
If all male factors arc normal, you may have:
7. Post-coital test (Sims-lliihner test). Just before you
expect to ovulate you have intercourse and visit the clinic
within several hours without washing or douching. 1 he
doctor takes a small amount of mucus from your vagina and
cervix to study whether, and how many, sperm have
survived in the cervical mucus.
We were supposed to make love at seven o’clock in
the morning and then I had to run to my doctors
for the post-coital test. Who feels like making love
at seven in the morning during a busy week
anyway?
I had to make two appointments for the post-coital
Ixrcausc the first time he couldn’t do it. 1 hey were
• very nice about it and said it hap|>cns all the time.
Thankfully, this test is now liecoming less common with
the advent of a similar test - a sperm/mucus cross-hostility
test - which can lx? done in a laboratory without one having
to provide a sample following intercourse.
8. Hysterosalpingogram (I ISG), which allows for direct
visualization of the tubes and provides a permanent record
that can be used for comparison if future X-rays arc needed.
Doctors usually perform this procedure in the first part ol
the cycle, before ovulation, to prevent possible X-ray
exposure of a fertilized egg if conception has occurred. It
involves injecting a dye into the vagina and uterus which
should pass up through the uterus to the tubes and out into
the abdominal cavity. If it docsn t, it means that the tube is
blocked, and that an egg is probably unable to pass through
it. A series of X-rays arc taken during this process. I’hc dye
then passes out into the surrounding cavity and your body
reabsorbs it. This test can be painful, and it’s a good idea to
be prepared for this. lake someone who can take \ou
home; learn some relaxation techniques to help you
through it. It's also woilh discussing pain relief with the
•Lee "I•!.<• Trouble with Infertility Tvsling’ in Rnknscn ami D.isidson, Out of
Our I hinds.
fit nun he possible for the man's bloml Io lx- tested for anti-sperm anhlxnlxs.
although this is a new area of research; antibodies can be suppressed by large
closes of corticosteroids.
•Blit since .ill X-r;i\s in the regiun nf the ox.ns .ire |x.t< nlialh li.uinhil tn
nnfcrtilizccl eggs loo. you in.u u .ml to Ix-.ir this in mind Ik Fore considering tins
test.
INFERTILITY AND PREGNANCY LOSS 427
doctor beforehand (it can be done under a general
anaesthetic).
' 9 Tubal insufflation (Kuhin test). T his is much less
common than the IISG test. Carhon dioxide gas is blown
under carefully monitored pressure into your uterus
through the cervix. Normally it will escape out of the lubes
into the surrounding cavity, causing shoulder pain when
you sit up. (It is eventually absorbed into your body.) If the
results are abnormal, it may be repeated or confirmed by Xray studies. T he Rubin test can indicate blockages but can’t
tell where they are located and can lead to pelvic infection.
10. Laparoscopy (a hospital procedure) which allows
■ direct visualization of the exterior tubes, ovaries, exterior of
the uterus and the surrounding cavities (sec p. 596) and can
yield a great deal of information, such as whether you have
small pieces of endometriosis at critical sites; treatment for
this may lead to pregnancy. Sometimes a dye is pumped
into the uterus during laparoscopy, to sec if it can pass
through the tubes and out into the pelvic cavity (see USG
above).
Feelings about Going for Tests
Clinics tend to be very pressured and you may rarely see the
same doctor twice. Some tests can be painful, and they can
also leave us feeling undignified and emotionally exhausted
and depressed, it takes a lot of strength to go through some
or all of the above tests. A good, supportive doctor makes a
difference; try to change your GP if yours isn’t. Relatives
may not be too helpful cither:
My parents arid parents-in-law want
grandchildren and make me feel a failure because
I’m not producing them. My husband wants
children very badly and sometimes reminds me that
other women could provide him with them. I
always feel guilty about my jealousy whenever any
of my friends becomes pregnant.
Jane and Ann had very similar experiences and feelings,
and derived much support from each other when they
discovered that they were not alone.
Jane: just decided we’d like kids and thought we
ought to go ahead straight away, as I was twenty
eight. As the months went by, the worry and
tension mounted. I was worried anyway as I d
always taken lots of risks and nothing had ever
happened, and I’d had gonorrhoea and knew this
could cause infertility. I he doctor wouldn t help,
as 1 wasn't married and he said my fellow would
leave me, and if 1 had a baby it would grow up
homosexual! The I'TA told me id got to try for al
least two years before they’d begin investigating
although I was worried about my age. I kept
getting ill with other things, and eventually saw a
partner of my doctor who was sympathetic and
could see the worry was affecting my health and
who referred me to the infertility clinic.
The tests were terrible and long drawn out well over a year. Never once were the emotional
problems referred to. Each new test was a major
trauma.
Ann: My tests went on for the best part of two
years. My overwhelming feeling was hoping
something would be found — I couldn t even be
treated if there was nothing wrong.
For both Jane and Ann, sex became very difficult.
Ann: This was one of the worst aspects, so
dominated by the idea of reproduction it ceased to
be an expression of anything for each other and
became much more mechanical.
» v
Jane: Quarrels assume enormous proportions when
they mean you don’t make love on the crucial day,
or terrible bitterness is caused when your partner
just doesn’t feel like it on the crucial day.
Ann: The other side of it is quite as bad - if you
don’t feel sexy on the ‘right’ day - it becomes
dominant enough to turn you off anyway. Thar
causes huge problems with any other relationships
too. I didn’t know which came first: the totally
unexpected feeling of jealousy or the idea that
someone other than I might conceive by my
'
husband. It totally squashed any ideas^or practice
wed had of not being exclusive - I couldn’t face
using contraceptives (emotionally) at that time and
couldn’t do to him what I couldn’t face and get
pregnant by someone else. And the aftermath - it
must have been nearly two years after the last tests
before I felt really relaxed and spontaneous about
sex again, which used to be good before it had to
be functional.
Not all people feel the pain of living through this period
with equal intensity. With luck we can call on help from
our partners, and can find support from close friends,
family or an infertility support group. * But we need to be
prepared for investigations and/or treatment to go on for
many years. Here, a woman GP who has herself had to
come to terms with being infertile speaks:
It is easy to let the tests and procedures take over
your life, and to lose your other interests. This is a
pity even if you eventually succeed in having a
child; if you don’t, it can be a disaster. So while
you are undergoing tests and treatment, it s a good
idea to make a conscious effort to develop other
•The National Association for the Childless secs as one of its main functions
the support of people going through tests and treatment for infertility. The
WHKRIC can also put you in touch with support groups. For addresses see p.
442
I
428 CHILDBEARING
sides of yourself- perhaps your career, perhaps a
hobby, or a network of friendships. If you end up
with a child, you’ll have more to offer as a parent;
if you don’t, your life won’t feel as empty.
TREATMENT
Drugs
The main drugs to induce ovulation arc clomiphcnc citrate
ci
(clomid), HOG (human chorionic gonadotrophin - a
.....
‘
'
'■ a id I IMG
hormone
extracted“from the
human placenta),
(human menopausal gonadotrophin - extracted from the
urine of menopausal women, who have very high let cis of
"
In this section we focus solely on ‘orthodox’ treatment. We
cannot discuss ‘alternative’ approaches in any depth
because so little research has been done in this area. This
does not mean, of course, that any alternative practitioner’s
claims of success are necessarily bogus, but it is impossible
to assess effectiveness without adequate research. Never
theless, most ‘alternative’ systems and techniques, if prac
tised well, aim to improve our general health and well
being - which can, theoretically at least, have spin-offs for
our infertility and in any case are potentially worthwhile in
their own terms.
I knew I couldn’t cope with batteries of tests and
medication. I felt the need to harmonize my body
and allopathic treatment would do the opposite. I
don’t know whether it was the acupuncture that
restored my fertility or whether the feeling of well
being simply made me feel relaxed enough to
conceive. Maybe it was just a matter of lime. But
th? treatment certainly made me feel better.
t
Most ‘alternative’ systems also have something to offer us
in relation to stress (sec Chapter 7).
Turning to orthodox medicine, we also have to report
that'no controlled studies have been done which would
clearly establish its value with regard to infertility either.
In general, male problems have so far responded poorly
to medical treatment with drugs, though surgery is
sometiipes successful. Insemination with your partners
sperm is sometimes used if his sperm count is low, in the
hope that with careful placement of sperm, the chances of
conception will be increased. This procedure is called AIH
(Artificial Insemination by Husband). A method of separat
ing out fertile sperm from others and inserting them directly
into the Uterus or using them for ‘in vitro fertilization (see
p. 429) is currently being tested; it is too early to know how
successful it is. If infection is causing a decrease in sperm
motility, it may be corrected by antibiotics. Otherwise, Al
(Alternative Insemination) is the only hopeful solution for
male infertility (see Al, p. 432).
For women, treatment of hormone disorders currently
offers the highest degree of success, although the advent of
microsurgery means that many more surgical problems can
be tackled compared with in the past.
-
________________ .a
1
\
I I ft 4 Z
the hormones LH and FSi I that induce ovulatiou). I IMG
': name is rcrgonal.
is also called mcnotrophin, and its trade
introduced
Clomiphene citrate was i------------------in the I96()s and is
commonly used. It appears to act directly upon the hy|po-
thalamus in the brain and causes it io produce more 1.11
and FSH. About 80 per cent of women will
■ill ovulate with the
help of this drug, and about 50, per cent will become
pregnant, with a slightly
J _ , higher risk of multiple
pregnancies. *
.
Potential side-effects of clomiphcnc include visua. dis
turbances, abdominal discomfort, a throbbing feeling in
the ovaries at the time of ovulation, hot fliishcs, nausea,
breast tenderness, depression, weight gam, skin rashes and
hair loss. Glomiphenc can over-stimulate the ovaries
(which can damage them): for this and other reasons, the
British National Formulary recommends that It should
only be administered under s|x?cialist supervision m care
fully selected patients.’ You should have a cheek-up at the
end of each cycle to check that the ovary is not being over
stimulated, but this is rarely done; you may wish to ask for it
and also to make sure that it is an appropriate treatmenttin
your case .(Pfeffer and Quick discuss the inappropriate use
of this drug - sec Resources).
HCG may Ik-combined with clomiphene It acts like 1.11
on the ovary and helps the egg ripen and release. Side
effects include headache, tiredness and mood cchanges.
potent
HMG is used to induce ovulation. It is a very
i
hormone and should only be prcscrikd whent dher hor;r.o::c treatment has failed. It requires particularly careful
monc t----------------monitoring to avoid over-stimulation of the ovaries, poss
ible rupture, and multiple pregnancies. This means that
you might have to travel some way to socialist centres. It
involves frequent injections and often daily visits to a
laboratory for blood and mine checks. I his can play havoc
with your life, and employers are not always understand
ing. ♦ Some doctors use ultrasound to monitor the develop
ment of the ovarian folliclefs).
Bromocriptine (trade name Parlodel), introduced in the
1970s, is used if levels of the hormone prolactin in the
blood are high (this occurs in a small minority of infertile
•Publicity has centred on ‘fertility drugs' Ixxausc they soiHctiiiivs cause
multiple births. If clomiphcnc is used canrcfully and the uorijaii is properly
monitored, it only increases the incidence of twins - at most. I’crgoual has a
higher risk (up Io a quarter of pu giumcics result in more th.to our fetus, iisu.ilh
twins).
i hlis managed to
I Following pressure from iufr rtilc women, one trade union
negotiate an agreement for infertility leave on a par with m;lalcrnits lease
•'lire effect of ultrawMiiul on the ovary is virlualk imkimUn.
over 60 per cent of infertile couples' pregnancies were completely unrelated
treatment.14
There is.
however, evidence Io tuggr st that the use of ultrasound on ov.ihes itoiiitd the
time of ovulation reduces fertility somewhat With regard to other |M»ssihlc
< ffccls, we are unlikely to know about them until the second generation.
INFtH I ilII'Y AND PREGNANCY LOSS 429
women). It appears that high prolactin levels can disturb
normal ovulatory patterns. Side-effects of bromocriptine
may involve nausea, dizziness, headache, constipation or
drowsiness.
The newest development involves LJIRH, the hormone
that enables LH to be released (LIIUH stands for I.Hreleasing hormone). Until recently, use of LHRH was
ineffective; then it was discovered that the key was to
administer the hormone in short, tiny bursts — mimicking
the way the body itself releases the hormone. Several
studies have now shown this treatment to be extremely
effective for women with certain types of amcnorrhoea (in
one study, out of twenty-eight women whose ovaries had
not responded to clomiphene, all ovulated, and all con
ceived, nineteen of them within three months). In addi
tion, the incidence of multiple pregnancies was low. Now
that a convenient, portable pump has been designed,
pulsatile LHRH administration appears far safer, simpler
and, above all, more effective for suitable women, than
gonadotrophins. Moreover, as Gut of Our Hands
concludes:
Because this treatment so closely mimics the natural
bodily process, in theory it is less likely than most to
have powerful side-effects.
Problems in the luteal phase of the menstrual cycle may
be treated with clomiphene, 11GG, and/or natural
progesterone.
Progesterone is given either as vaginal pessaries or as
injections. Side-effects include weight gain, gastro
intestinal disturbances, breast discomfort and acne. Syn
thetic forms of progesterone (progestogens) arc not advised
as they can be harmful to fetal development.
Cervical mucus problems, depending on their cause, are
treated with hormones or a form of steroid (not a common
treatment; effects arc fluid retention and masking of other
infections). Special douches can help if the mucus is overly
acid. Diet may help too (see p. 425).
Deciding on what treatment to go for, and for how long
can be difficult.
Only you can decide where to draw the line . . .
Properly administered and monitored drug treatment
for female infertility can be extremely successful.
However, as with all medical technology, somedoctors are better at using it than others. If you arc
thinking about drug therapy you should be aware of
the potential complications and side-effects and be
prepared to stop if these get too serious. Drug treat
ment is something of a balancing act in which you
need to weigh the desire to have a baby against the
possible costs.17
Apart from the costs Io you, you may also need to
consider the possible costs to the baby. As with all drugs
taken during pregnancy and around conception, there is
the theoretical possibility of causing damage to the fetus-.
With regard to embryos resulting from drug-induced ovula
tion, it is possible that many may have limited potential for
continued development at all.18 In addition, there have
been reports which suggest that clomiphene might be
associated with feta) abnormalities.19
Surgery
Surgical techniques can often correct structural problems
of the uterus. It is also possible that dilating the cervix may
improve the chances of conception; this was discovered as a
by-product of IVE (sec below).
The development of microsurgery (involving the use of
very fine instruments, guided by a microscope) has made it
possible to try and repair blocked or damaged reproductive
organs. Successful pregnancies following microsurgery are
quite high at the Hammersmith Hospital in London (over
50 per cent for certain types of problem).* However, they
have pioneered and developed the techniques at the Ham
mersmith and success rates are unlikely to be as high where
staff have less experience; nor is microsurgery generally
available, because doctors have been slow to pursue it.
Instead it appears that they much prefer IVF, partly because
to do microsurgery well you need to be extremely skilled.
Gamete Intrafallopian Transfer (GIFT) is basically a
surgical technique that has been developed recently, where
eggs and sperm are placed in a fallopian tube together,
under laparoscopy (see p. 596). Obviously it is iiiipossiblc if
both tubes are blocked, but it has already been used with
egg donation (see p. 430), for example, where women have
had a premature menopause or had their ovaries removed.
Birth rates with GIFT have been quoted as one in four in a
Lancet leader,20 but no reference is given for this figure.
Laser surgery, for example to clear the follopian tubes,
could also be a possibility in the future - the first baby
conceived following laser treatment was born in Glasgow in
September 1988.
1
j
In Vitro Fertilization (IVF)
IVF involves a variety of procedures, so we are devoting
quite a lot of space to explaining what is involved. By doing
• this, we do not mean to imply that IVF is a viable option for
many women; indeed, there may be a case for pressing for
the availability of more microsurgery than more IVF
programmes.
In vitro is l-itin for ‘in glass’. At its simplest, in vitro
fertilization involves extracting a ripe egg from the ovary,
fertilizing it with sperm in a glass dish (not a test tube, as the
media would have it) and replacing it in the womb. At the
time of writing, it usually involves the following.
Hormonal treatment with gonadotrophins (see HCG
and HMG above) to get several eggs to mature so that
more than one embryo may be implanted at the same
‘The success rate depends on the extent of the damage. It can be as low as 10
per cent. Possible adverse effects of surgery also need to be considered: from
aii.it sthclics (see |>' S^bJ.'rcTormation of scar tissue or post-operative infections.
—- ■
Association of India
Valued Health
L
430- CHILDBEARING
time which increases the chances of a successful preg
nancy — see below)
Ultrasound examinations (see p. 368) and hormone
level checks, in order to ascertain when ovulation is
about to lake place (the eggs have Io be collected just
•
before they woidd normally be released). Ultrasound is
also being developed to enable collection of eggs on an
outpatient basis via the vagina - as opposed to on an
inpatient basis involving laparoscopy (see footnote on
p 428 about possible effects of this).
Removal of ripened cgg(s) from the follicle in the ovary
r
by means of laparoscopy (see p. 596); (the extraction
procedure is not dissimilar to the procedure involved in
•
amniocentesis (see p. 370).
Placement of egg(s) in a sterilized dish containing
nutrient solution, to which semen is added; the dish is
then pladcd in an incubator so that fertilized eggs can
•
jstart to grow.
'Several embryos (technically still conceptuses at tins
stage) arc transferred to the womb in the hope that one
of them will attach itself and continue growing. ( This
can possibly lead to multiple pregnancy.) The transfer
oral process involves a similar procedure to inserting an
IUD (see p. 287). Other embryos (if any) may be frozen
and stored if subsequent IVE attempts arc required.
The first child from such frozen beginnings was born in
1^4.
As with the initial stages of most technological innovaionsr- from X-rays onwards - doctors have argued that the
It could, however, be used for a lot more women, including
those with 'unexplained' infertility;22 there have also been
reports of some IVF successes where male infertility was the
problem, for example because of inability of sperm Io
survive in llic cervical mucus.
You (lou t ncccssaiily have Io be iiiaiiicd. but a male
partner is required, and we know of no eases where lesbians
have had access to IVI* using donor sperm.
1VE is being practised (with emphasis on the word
‘practise’) in relatively few clinics, and it has a low rate of
success. We can be forgiven for assuming the success rate is
good because of the media hype, and also because the
doctors involved tend to restrict their programmes to heal
thy women, usually under thirty-five, and carefully avoid
talking about the numbers of births, restricting themselves
to the number of pregnancies - which sounds more
impressive.24
Usually it takes several attempts before implantation is
achieved, let alone before it proceeds to a live birth, if at all,
and the chances arc lower for some women than others (so
far, the success rate declines with increasing age). While
many of us arc prepared to come back if it is unsuccessful,
clinics may limit the number of times a woman can try.
While 1VE is arguably high-tech, it is certainly high cost
at present, * and is mainly an option only for the well-off. It
also causes tremendous upheaval, with daily, and
sometimes more frequent, visits to hospital for tests.
1VE, though as yet possible only for a few, and successful
for even.fewer, opens up two more possibilities: egg dona
tion which enables IVE to be performed using another
risks are negligible. They have been proved wrong many
times, including in relation to X-rays, the administration ot
certain hormones in pregnancy, and numerous other pro
Woman’s egg (the first such baby was born in Australia m
cedures. It is difficult to ascertain what effects if any there
might be from IVE and all the procedures involved. Many
of the procedures (such as hormone administration) have
an embryo, or where to produce such an embryo would be
themselves been used as infertility treatments for far longer
than IVE, and we know little about their effects either.
Doctors argue that if an egg or embryo is damaged during
IVE, it simply won’t develop. But we don’t know whether
that’s true until thousands of babies conceived in this way
have had a chance to grow up, and possibly reproduce
themselves. As far as freezing of embryos is concerned,
condemned by the Royal College of Obstetrics and Gynae
even less is known about the risks.* However, set against
any possible risks to the fetus are (1) the fact that the tuning
medical and political sources will aim to pul tight controls
of embryo insertion can be chosen so that it is most
favourable for implantation (the administration of hor
mones can throw off the cycle), and (2) the lessened risks to
1984); embryo donation, likewise, is a possibility, where
neither partner can produce gametes for the production of
genetically risky. (The use of a surrogate mother - see p.
4S6 - to carry an embryo conceived by another has been
cology Ethics Committee.)
These techniques mean that more than one man and
woman can contribute to the many stages involved in
creating a fertilized egg, carrying it in pregnancy and raising
the resulting child. Illis brings up many social, emotional
and legal questions. It is likely that pressure from religious,
on how this technology is allowed to be used.
INFERTILITY TREATMENTS: THE DILEMMAS
the woman, who in the long run won't have to have a senes
THEY RAISE
of operations each time IVE is attempted.
IVE is usually considered only for a woman whose
ovaries and uterus appear to function normally, but whose
fallopian tubes can’t function, although it seems to be
The development of IVE, egg transfer, eteetera and fuhne
possibilities (sec p. 6B) has led Io public concern and
stimulated debate about the development of reproductive
tcchnologv in general As far as women arc concerned, they
particularly unsuccessful for women with endometriosis.
•Iluwnxi. as a ka<icr arlidc in the Bn/A/i Medical /ournal (2H July I'jb4|
suggests, cvculunlls. IVI* could lx .1 <hc..|xr «:is <»t tic.iting iidcftdily lh.11.
Along the v.n.c
hues. The Hntcet IS IXceh.lxr I WI)
Mine lines.
suggested that IVK might cv< nfualh lx pHuhlc on a d:iv tare. out|>.ilieiil bauv
current ukIIkkIs
•The same applies Io frozen
- if and when cer freezing is found to I*
successful (which may well he by the lime you read Hus).
L
INFERTILITY AND PREGNANCY LOSS 431
herald the need to question afresh what the implications arc
when doctors - and possibly the state itself - intervene
regarding decisions we can make about our own bodies (in
the same way that both intervene now with regard to our
right to choose abortion). While many of the Warnock
Committee’s recommendations arc helpful,25 they barely
consider women’s rights: for example, the committee felt
the need to ‘discourage’ widows from using husbands
frozen sperm, and concluded that ‘as a general rule
children should be born into two-parent famihcs, with both
father and mother. 'The report thus lends support to many
current practices which are, by the time you read this, likely
to be enshrined in law.
,
Yet despite the media hype about ‘test-tube babies, the
resources available for infertility treatment have been con
sistently very low, resulting in scandalously long waiting
lists, and poorly coordinated research and treatment.
Infertility is a low priority issue, and will remain so unless
wc make our voices heard - through orgamzations such as
Wl 1RRIC and the National Association for the Childless.
It ii particularly important now, with medical interest in
the newer technologies, that progress is clearly m he
interests of women. 'There is much glory to be gamed by the
predominantly male medical elite which is jumpmg on the
‘test-tube baby’ bandwagon, and this search for glory
(which may well be connected to a more unconscious
search for the ability to give birth) can all too easily obscure
the issues as women might sec them.
Medical approaches to infertility, as currently practised,
represent yet another example of bow doctors arc develop
ing high technology ‘solutions' to the exclusion of:
1. improving their all-round services and developing an
understanding of preventive strategics which could serve
many more of us. Tor example, they could emphasize and
promote the importance of good gynaecological practices
less damaging forms of contraception, and sheer good
nutrition. Indeed, it is possible that many of us who end up
wanting infertility treatment would not need it if we had
known about possible causes and preventive measures ana
if our doctors had been more careful;
2 considering the effects of their treatments when they
arc unsuccessful - which is the case for many women, and
the vast majority of us when it comes to such procedures as
‘
IV1'3.’ considering the overall effect of (heir achvitlcs m
support of the ideology of molheihood. Perhaps we would
feel less obliged to put ourselves through semi-permanent
emotional turmoil and what arc often extremely mvas.ve
and al times degrading medical manipulations if a woman s
worth in our society were no longer measured m terms ot
her fertility.
.
Approaches to infertility treatment can represent a tech
nological fix for something that has at least in part been
socially created/ Sometimes the treatment works ... or
• I llis IkIics Ihc question of how often we are told alxiut the chanees of success
of any pailicular licatincnl.
we manage to have a child anyway. All the torment and
treatment then seem worthwhile. But the very existence of
sophisticated treatments, however slim their chances of
success, can simply increase the pressure on us to try
everything - with all the attendant pain and uncertainty
that this process entails. It can make it all the more difficult
to accept what may well have to be a fact of life for us.
I used to cling to every story I heard about people
having babies against innumerable odds, as I wanted
so much to believe there was hope. It made adjusting
to the whole problem so much harder.
We also may suffer from the attitudes of other people,
perhaps friends or family, if they see technology as the
answer to our (and perhaps their) problems.
I feel trapped in other peoples belief systems. It s
like I’m not allowed to give up hope. But until I
do I can’t begin to really live again.
And as a psychotherapist says:
It’s very problematic helping people come to terms
with infertility if a baby is something they might
be able to have, however remote the chances are,
if, say, they undergo IVf.
Coping with living - as with dying - is painful. Tech
nology can help. Sometimes. But if we look to it as the
answer to our pain, we court disaster. It can creates prison
for us, particularly if that technology fails us. Yet through
our pain we can discover parts of ourselves, of others, of
life that enrich us beyond our wildest dreants. Maggie
Jones ends her Ixxik Trying to Have a Baby? with the
following quote.
I remember walking up the hill - it was a bright dayjn
early summer - after having the final results of the
tests and thinking, that’s it, I shall never have chil
dren. The thought gave me a lot of pain, but as soon
as 1 had thought it, I had ihc sensation of a huge
weight being lifted off my shoulders, I no longer had
to go on thinking, if, when, somehow, If only ... it
was all suddenly settled. I walked past the children’s
playground on the corner of the street and two small
boys were playing on the swings. I stood and watched
them for a while, and again, 1 was no longer thinking,
if only, perhaps one day, and feeling that familiar stab
of jealousy; instead I was standing in the warm
sunlight and listening to their high, clear voices with
something approaching joy. Suddenly I felt com
pletely washed clean, and at peace - and freer than I
had ever felt in my whole life.
We must try to ensure that any available medical help
recognizes the problems that that very help creates for us.
We need to ensure a more sophisticated understanding by
432 CHILDBEARING
the medical profession of the repercussions of infertility,
and guard against their using their power (yet again) both Io
protect themselves from their own pain at being of such
limited help and/or to exercise powerful control over us.
We must guard against doctors playing god - not just in
terms of wanting to produce babies themselves (consciously
or unconsciously) but also in terms of deciding who
‘deserves’ their treatment. Doctors’ ‘power-tripping’ over
women is linked to all reproductive issues, not just
infertility. The difference is that, with infertility, it can be
harder to see what’s happening because of the intensity and
corrtplcxity of the emotional pain.
COPING WITH INFERTILITY
It is difficult and painful to acknowledge that our infertility
is permanent. Particularly when there are no clear-cut
medical reasons for infertility, it can be difficult to know
when to stop the investigations and treatments, and to put
away the thermometer. Feelings of hopefulness may give
way to .depression. We now have to begin to examine our
lives. Wc may feel grief for the loss of a part of womanhood
or manhood, for the parts of us that don’t work or have been
cut ouhof us. If we deny or repress this feeling of grief, wc
prolong the process of its resolution.* Somewhere inside
we arc dealing with the experience. Wc have the choice of
living it as consciously and directly as wc can or suppressing
these very natural but painful emotions. The pain of
infertility is never completely resolved but is accepted as a
familiar ache which may recur, unpredictably, throughout
life. Grieving often takes a long time.** The support of
friends, family and other people who have experienced
together, as I rarely thought of my infertility and
was very active.
Then, for no obvious apparent reason, my
infertility again became a prominent concern, and
all the feelings I had submerged five years ago
resurfaced. After four unstable months I ended up
in severe, crippling depression.
Only with the help of counselling have I been
able to l)Cgin to work through the feelings and to
come out of my depressed state.
I share this only in the hope of helping someone
else not to fall into the trap of thinking they have
worked through to resolution their infertility, when
in reality they have only dealt with the problem on
an intellectual level. The pain of the past four
months has been as intense as when I first learned
of the diagnosis of infertility. I feel that somehow I
failed myself because five years ago I was too
frightened of the pain to face it. I he truth is, it
has to be faced sooner or later, and hopefully all
the way to resolution.
It was relieving to meet and talk openly with other
couples experiencing infertility. Each of us had our
own specific difficulties but our feelings and
reactions were quite similar. After the initial
nervousness that accompanied our first two
meetings, I began to feel much more accepting and
able to deal with the previous two and a half years
that had given us two pregnancies and two
miscarriages. My almost constant obsession with
pregnancy was lifted. I began to feel in touch with
myself and somewhat alive again.
infertility can be helpful.
ALTERNATIVE INSEMINATION (AD*
Last year I had a hysterectomy at the age of
twenty-nine. Needless to say, I was crushed with
grief I never had the chance to have a baby and
then all hope was snatched away. In my case it
had to be done - fibroid tumours had practically
destroyed my uterus (there were twenty-one, to be
exact). I was very bitter for a while, but now I am
healing. That is not to say I don't hurt sometimes;
I think a pain this deep will always come back
from time to time.
After learning of my untreatable infertility five
years ago, I experienced the usual shock and
denial. Unfortunately, I pushed down all other
stages and feelings by submerging myself in work.
Eventually we adopted a son and all seemed right
with the world. I thought I had everything
This can lx? used by single or lesbian women who do not
wish to have intercourse in order to become pregnant, and
also by fertile women whose partners are infertile.
Al is a technically simple procedure that can be done in a
clinic or at home. A fertile donor male masturbates into a
container (clean, preferably boiled and then cooled). 1 he
sperm may be frozen and put in a sperm bank, or it may be
used fresh - in which case it should lx: kept at Ixxly
temperature and inserted into the woman’s vagina as near
to the cervix as possible; as sperm die fast, insertion should
take place as soon as possible after thawing or masturbation,
within two hours at the outside. Al should take place
around ovulation, so you need to establish tins in advance
(see Fertility Awareness, p. 37).
A clean, nccdlelcss syringe is usually used to insert the
semen but women doing self-insemination on their own
have used anything from eye droppers to turkey hasters.
The woman lies Hat on her hack with her rear raised on a
• Io c<.|K_• wilh infcTlilily tests
•Since we often need to repress our feelings in order
is particularly important to allow ourselves Io feel them at
and treatments, it i
some point. ,.v ...rmcdialely block this feeling of grief by planning Io adopt,
••Some people imi
is more likely to be happy and successful if yon can work out the
The adoption L —
grief.
•This is the te.m being in.
gb used bv
medical circles as Artifici.il liiscniinatiim by
»lut ts desenkil tn
(AID)
a
INFERTILITY AND PREGNANCY LOSS 433
pillow. Ideally she should stay like that for half-an-hour so
that as little semen as possible leaks out of her vagina. Al
may be repeated on successive days if frozen semen is used;
or alternate days with fresh semen from one donor. On
average, women who become pregnant from Al do so after
trying for three to five cycles; at Bl’AS 40 to 50 per cent of
couples achieve pregnancy within a year. If you aren t
pregnant after having tried for six to eight months, you may
want to explore the reasons at the clinic or hospital.
C*ctting Al can be mu. i imue problematic than the
technique itself. Currently il is not widely available on the
NHS, and there arc long waiting lists; those clinics that do
provide a service often restrict it to couples where the man’s
sperm production is very poor —as opposed to just averagely
poor. I hey often decide who should receive Al on the basis
of whether they consider you to be a suitable parent. And as
a Lancet article on A! in 1982 concludes:
Sonic practitioners provide AID services for single
women, for lesbian couples, and for people with
psychoscxual difficulties — when there is clear
evidence that children brought up in such circum
stances can be seriously disadvantaged.28
It is worrying that such prejudiced and ill-informed
attitudes can masquerade as scientific truth. (See chapters
on relationships.)'This attitude is reflected in the Warnock
Report (though in a more circumspect manner), which in
addition recommends that the provision of Al. without a
licence for the purpose should be an offence. While this
recommendation, if enacted, should ensure a well-run
service (something that is not necessarily the case at the
moment), it does not augur well for those of us deemed
‘unacceptable’ either because of our colour, class, disability
or sexual orientation, whose only recourse would be
se/f-insemination. *
Until we arc able to improve the NHS service, many
women therefore consider seeking Al privately. Some
clinics have been known to charge scandalously exorbitant
sums (upwards of £1,000 per course of insemination).
Others, like the charity BPAS (see Resources) are nonprofit-making (BPAS currently charges a maximum of £40
for two inseminations per month; there are additional costs,
e.g. for counselling and initial examination). If all A!
clinics were regulated, they would at the very least be
obliged to offer a suitable service - ensuring first the
anonymity of both donor and recipient (which can forestall
possible emotional and even legal complications) and
secondly that all donors arc properly screened for possible
health problems, particularly HIV, the virus that leads to
*l'or more ubool .scll uisciiiin.ilioii, see Rcsomccs or conlacl Wl IRRIC. Since
Al is sueli u simple ptoeedure. us many tloclors ucknoveledije, >ittempls Io
restrict ils use illuslhilc |>eiliiips even iiinrc c Ic.iil) lli.m ihc ulxitlioii issue the
extent Io which il is (Iceiiied lli.il uonieivs light to conliol our own IxkIics
should nol exist. However, ul pic.seiil ;il leiisl, sell inseniiiiulioii lem.iiiis leg.d
AIDS(secp. 501). Because of the risk ofcontracting 11IV or
other sexually transmitted infections from donors, it is
important that all donors are adequately screened. Highrisk men are advised not to donate sperm. Current Depart
ment of Health recommendations are that, to allow for
a valid test for HIV, all semen should be frozen and stored
for three months. (Conception rates with frozen semen
are slightly lower than with fresh, but this may be con
nected with busy clinics not defrosting semen carefully
enough.)
All clinics should have access to sperm banks. This
means you don’t need a donor on call to produce semen
when you ovulate; finally, although insemination often
takes place.in a clinical setting, some clinics send you home
with special portable containers for the semen, so that you
can do it in less stressful surroundings with a partner.29
A big problem with Al is the shortage of men willing to be
donors, particularly men who are from minority groups. If
male readers and partners of women readers would consider
becoming sperm donors, there might not be such a
problem.
Deciding on whether to try for Al, and the process of
trying, can both be very stressful.
I’ve never felt so isolated in my life. Despite
comparatively few hassles and BPAS being very
encouraging, I was going through it as a single
woman. There was no one else as interested or as
committed to this baby as I was. In the end, I just
couldn't cope any more with watching to see if I'd
got pregnant, getting false symptoms, not being
able to concentrate on anything else. I was aware
of every movement in my body. Then there were
the emotional demands of going to the clinic each
time. It all got too much and I decided I couldn't
take any more after nine months of trying.
I never expected it not to work. But after three to
four attempts, I began to worry. I started
‘
remembering all the women I knew who needed
more than a year to get pregnant to try to make
myself feel better.
\
Some women have said that Al made them feel they were
committing adultery or lx?ing promiscuous. (The Roman
Catholic and Orthodox Jewish religions considct Al
adultery.) As you think about your situation, as well as
about alternatives (including structuring your life without a
child), you may find it helpful to talk with others who have
used Al, and to read about other women’s experiences.
Listed in Resources arc publications and organizations that
may be helpful. There may also be an infertility support
group in your area that could help.
If you decide to try for Al, it is important to consider what
you will tell close friends and family and - most importantly
- what you will tell your child. Many parents in the past
have kept Al a secret, but it is gradually being recognized
*
434 CHILDBEARING
. that sccrctiveness can create problems for Al children, just
as it creates problcn,is for adoptees.
Our daughter is really extraordinary - enormous
energy, very strong-willed and totally differentlooking from either of us. I am reminded
constantly that her father was a stranger.
Mv husband and I had more than our share of doubts
■ moment* ofr our daughter s birth.
right up until■ the
all our doubts
When we saw our baby
1 1; girl,
:
Eraucic Hornslein, discussing Al for lesbians, wrote m
-i.
My decision to conceive a child by donor insemina
tion was a long time coming. It was nearly seven years
between the lime 1 Gist considered the possibility and
when I began trying to gel pregnant. I he one lecuiring reservation in what had become a passional'
passionate
desire to have children was my fear o how Ire
children would cope with being from a different kind
of family. 1 knew 1 would be sorry >f 1 never had
children; sorry not only for giving up a part of lite
' really wanted, but for not making a decision I
believed was right. 1 felt I was as worthy of having
children as any other person. To not have children
simply because I was a lesbian would have been
giving up on a goal that was very dear to me.
who plan to
Hornstcin says:
Wc need to establish and protect the rights of partners
of lesbians who may not be biological parents of the
child, but who may be parents in every other sense o
the word/7
adoption
' ; to have a baby, 1
After we had stopped trying
baulked at the idea of adopting a child - bearing
one, having the mixture of ius had seemed
well
important as i.
— as
— living
« and changing with a
' I never
child. I felt I had to really believe 1 would
consider
produce children before I could even c::::c:'
Al ch
than producing one.
My sister-in-law hasn't been able to have childicn.
It's been very frustrating for her. But, allhoug li it
it 'fis
still very rare in our Asian society, she's adopt rd
two children. It s made her very happy.
While adoplinii
arloplion mav he an alternative In romidri Im
While
disappeared.™
1984.
udopting because i/ I had the slighlesl perhaps in
i
my head, I couldn't know I would totally accent
an adopted child. That took <r long time. Bill t
gradually became clear that living through growing
up with a child was far more important to me
3 gr£
|lh , of soinc research on bl<Mxt is the discovery
town.Xu <0 per cent of husbands could not poss.bly be
many of us,* it is becoming incieasiiigly dillirmil I i adopt a
baby unless s/he has a form of mental and/or physical
disability ** Although it is impossible to be prec sc about
waiting times, a wait of at least two years is not one mmion.
i.'... children will,
|«or
with 'snccial
‘special needs'
needs’ (i.c.
(i. any i hild ovlcr live 01
anv child with a han<li< ap). ihc w;.iilinr, p< ii«»<h mav Imninth shoilct.
Organizations sncl. as Parent Io Parent Inforn ahon on
Adoption and I'amily Caie (see p. 112) lane ‘ ligiiKilcd
the idea of holding group discussions for prospective adop
ters. it can be very helpful to talk over thoughts an I feelings
..... .
in an atmosphere free from the pressures of an interview
with a social worker or «ilh an adoption agency, .vlicre we
arc likely to feel under a great deal of pressure to appear
‘perfect’.
Getting together with other would-be adopter s of
special needs children was very important and
helpful to me. Socially I didn't know anyb^ly who
klc me
had adopted a special needs child, and it mcc.
feel very sane and good about what I was doing.
One of the best things about the adoption group
was sharing experiences of loss people had
experienced (infertility, miscarriages and children
dying), and being able to acknowledge my
r- own
grief in losing potential children of my own was
very important in the process of preparing to adopt
a child. Somebody elses child isn 't second best,
neither is a special needs child less ‘gixxl thifii a
‘normal' child. It is about the resources youi have to
give and being able to fulfil your own ineeds
---- in
since
mo^it
that giving that is important, and
oeople who apply to adopt have experience ^f loiws
around children, it seems to me that help to grieve
is an essential part of preparation for adoption.
• II.ourIi bear in nnnd that .Kl..plH»n aticiicK S li.nc .1 •< vilu U iiqc liiml on
pI.,«xt live aduphve pa.cnh
Iwec. ll.i.lj-r.ve an. In.lv x.v.n.
- nn. n par.lv kxauH- of lln- Al-bnn Ad. .mr p.nllv l«J1'1 s«KKt;>l
mlc p.ircnh.
atWn.kn have n...<k i!
I.................. h""“
y
I with
a. ,c. it n .1.11 ... ................. ..
............ ........
5■'
a disability on sour ossn
lh<- ■ ithers of their children.
INFERTILITY AND PREGNANCY LOSS 435
THE PROCESS OF ADOPTION
If you try to adopt, the process can be long, difficult and
painful, so be prepared. You may have to try a large
number of agencies, particularly if you arc trying to adopt
an able-bodied baby. Some agencies close their lists if they
know they will never be able Io Imd enough children for
prospective adopters. Most arc choosy - though their
criteria will vary. You will have to give up any infertility
treatment.
Adopting a ‘special needs’ child can in theory be a lot
easier. Parents for Children, an organization concerned
solely with placing special needs children with adoptive
parents, has opened its doors to less conventional would-be
parents, and many other agencies have followed suit. As
Parents for Children says, special children need special
parents. Often people with unusual relationships, lifestyles
or life experiences arc more successful at parenting children
with multiple problems.
To adopt a child, you will need to approach either your
local authority (in which case, write to the Director of
Social Services) or a registered voluntary adoption agency.
It is illegal to adopt through any other third party, unless
you are a relative of the child or you arc ‘acting in
pursuance of an order of the High Court’ (Children Act,
section 28). You have to go through an approval process
which might take a few months. It involves being allocated
to a social worker with whom you will have several inter
views. If you are in a couple, you arc seen together and
separately. You will also have another interview with a
different social worker. Police records arc looked into and
you also need to go Io your ('.P for a medical; your CP will
be required Io furnish a report to the social worker about
your medical history.
/ think I was lucky. My GP discussed with me
what should go in his report. I had had a period of
depression some years before and he was aware that
the way he presented this information might make
a difference to whether I was approved of or not.
Then your ‘case’ goes to an ’adoption panel’, which may
include professionals as\vcll as adopting parents. The panel
is the approving body, although in practice most seem to go
almost entirely on the social worker’s report. Social work
ers, therefore, have a lot of power (though they arc at times
overridden). If you don’t feel you're getting on with your
social worker, you can ask for another one. You can also
check whether the particular adoption agency concerned
has an appeals system in case your application fails. II it
doesn’t, all you can do is try another agency.*
* You can also Iry Io adopt from abroad, lliom;li lire issue of removing children
front llrcir cnllnic and roots is very (<*niiovcrsial. Tire least |>olenlially
exploitative approach is lliiongli a govrinnicnl agemy. BAI 'A arid I’arcnt Io
I’arenl have lists of Ixina fide agencies abroad Beware miscinpnloiis ones llral
kidnap children lioni ’Urinl World connhics: in 19K8 a conference ol lire
Inlcnralional Bar Association was (old by Margaret Bennett, a Lindon
solicitor, llral approximately 16,00(1 newborn babies were likely to have been
alxhiclerl from llrcir molln is' bedsides each year nr Brazil alone
'flic adoption process raises many negative feelings,
often surprisingly similar to the ones experienced during
the first stages of coping with infertility. Feelings of
powerlessness, anger and frustration arc common, especi
ally during the time of the approval process when the social
worker is evaluating and ‘testing’ you on your potential as a
parent. Families and friends may not be as supportive as
you would like, and you may go through periods of anxiety
and desperation.
My husband and I found out we might become
prospective parents in April. That gave us about
seven to eight weeks to think about this. I had
many things going through my mind. So many
things could happen in the interim. The natural
mother could still change her mind. I wondered
what the child would be like. The baby’s looks,
personality, health - everything is unknown . . .
I thought a lot about bonding. I wondered what
I’d feel like when someone put an infant in my
arms saying, ‘Congratulations! You are a mother.
This is your child.’ Who is this stranger? How am
I supposed to love someone I do not even know?
How am I supposed to feel? / believe these are
healthy feelings, but still it is frightening to think
about . . .
I believe couples facing adoption go through the
same feelings that biological parents go through the fears, insecurities, the great change of lifestyle.
The only problem is that you do not have nine
months to work your feelings through. It is like
being told you are eight months pregnant.
I have found most other people trying to adopt, feel
desperate to have a child. I had all sorts of feelings
of divine intervention stopping me from having my
own.
It is quite normal to feel desperate in a society that tells
you that having your own child is the only way you can
have that particularly special relationship of responsibility
with a child growing up. Also your dependence on the
approval process can bring up all the previous powerless
feelings of depending on fate as to whether you vVill ever be
able to have a child or not. However, the process may in
fact be very helpful. A single woman speaks:
My experience of the ‘assessment’ process was very
positive. I was lucky in having a social worker who
obviously had a lot of respect for me right from the
start and so I felt safe to express all sorts of
y
feelings. It gave me a chance to explore all the
feelings and questions of why I wanted a child,
what was it about a child that I wanted and I
found I did really want to be with a young perspn
growing up and discovering the world and I would
be quite happy to do that with a child\vith a
physical handicap. Five months after this process
436 CHILDBEARING •
was begun, I was approved as a potential adopter,
and have since adopted a child with 'special needs'.
However, fostering itself is by no means easy, l orming ties
with a child can be very difficult if you don’t know when
s/he’s going to be taken away, and children’s responses to
Once you have been through this process, you are likely
to experience all sorts of feelings resulting from your
decision being officially approved. You are one step nearer
the possibility of having a child. You will feel a mixture of
cxeilcmciil, anxiety, vulnciabilily and joy al the piospevl of
a child being placed in your home. But be prepared that
thing.imay still not be easy, and whether they are or not,
you will'still need the support of family and/or friends.
Usually there are several people who arc informed about
a child awaiting adoption. All of those arc likely to want to
be considered, and will therefore go through the process of
mentally and emotionally adjusting their lives in anticipa
tion. When the prospective parcnl(s) have been chosen,
this can be emotionally devastating for the others. And this
process may be repeated several times.
Adoption poses a number of problems which prospective
adoptive parents need to think about in advance. In particu
lar, when adopted children start Io grow up they may have
very powerful feelings about being adopted which they do
not always express. The Children Act of 1975 also gives
adopted people the right to see a copy of their birth
certificate wb.cn they reach eighteen.
It is important to recognize the suffering of ‘birth
mothers’ - as they arc now called - who have had to give up
their children for adoption. To do this is not an easy option,
nor is it a decision that is possible to forget. Increasingly,
birth mothers are beginning to speak about not being able to
have contact with the children they have given up. Many
birth mothers can never begin to heal from the ‘surrender’
experience until they have been reunited with their
the situation arc understandably confused.
children.
The few studies concerning the adoption process which
have been done demonstrate that the feelings and experi
ences of all those involved in the adoption process arc often
neglected. We need to challenge the assumptions and
practices of social workers who label certain feelings and
lifestyles 'abnormal’ and distort the experiences and needs
of adoptees, birth mothers and adoptive parents alike.
SURROGATE MOTHERHOOD
FOSTERING
Fostering is a way of providing a home for a child who
cannot be with its own parents - although they arc still the
parents. Usually, but not always, the aim is to enable the
child to return to the original family at some stage. Foster
ing can be short- or long-term, or ‘fostering with a view to
adoption’. Many people have successfully adopted after
taking this latter fostering option, but securing the adoption
can be a long and painful process, and there is always the
chance that it won’t go through.
The process of becoming a foster parent is easier than for
adoption because it does not require the approval of the
courts and is solely at the discretion of the local authority.
This means that people with ‘unconventional’ lifestyles,
including single women, arc more likely to be able to foster.
ADOPTION AND
FOSTERING FOR
LESBIANS AND SINGLE
WOMEN
The law now states that a single person or a married
couple may adopt (an unmarried heterosexual
couple cannot adopt as a couple). At least one locai
authority - Hackney in London - has changed its
policies so that lesbians may adopt or foster chil
dren, and a few other authorities, such as Camden in
London, are considering similar moves. Single
women, including lesbians, have boon fostering
children for years. The only change in recent years is
that this is now being acknowledged more publicly.
We do not know how recent changes in attitude
towards homosexuality, condoned and promoted
by the present Thatcher Government, may affect
lesbian parents of all kinds — either now or in the
future.
Practised in its simplest way, this involves one w )inan - the
surrogate — bearing a chdd that another woman raises .is her
own. Where a woman in a heterosexual relationship is
infertile or unable to give birth herself, the possibility may
appeal to use her partner’s sperm to inseminate a surrogate,
cither through intercourse or Al.
Surrogate motherhood raises a host of social, legal and
financial questions. Much discussion followed media
coverage of the first known surrogate birth in the UK, with
the result that it is now illegal to advertise for, or offer,
surrogacy, and for all third-party intervention on a com
mercial basis. However, surrogacy arrangements on a nonprofit-making basis arc still legal according to the 1985
Surrogacy Arrangements Act. Nevertheless, it is another
kl be enforceable by a
question whether such contracts would
court of law.
The Department of Health has recommended to all local
authorities that any child of a surrogacy arrangement
should be made a Ward of Court if there is any indication
that the child might be at risk, thus endorsing what
happened in the ‘Baby Cotton case, where the child was
h. pt ‘in care’ (but actually deprived of parental care) for the
lust ten (lavs of its lift. Allhough it is still legal to make a
Public Policy OMsk®
Voluntary Health AssociaUon of Indw
€
I
INFERTILITY AND PREGNANCY LOSS 437
tjon-coinmcrcial surrogacy arrangement, the courts may
pregnant, about one in six pregnancies ends in miscarriage.
well intervene where the people concerned were in dispute
(e.g. if the surrogate decided she wished to keep the baby).
About 75 per cent of these occur before twelve weeks.
Miscarriage, then, is a fairly common evpnt. Wcnecd'tobe
At the time of writing, the possibility of further legislation is
at least minimally prepared to know how it foils and what to
being considered which could confirm the unenforce
expect. Miscarriage is both a physical event for a woman
ability of all surrogacy contracts. Meanwhile, an additional
and a serious emotional crisis which may be shared o,
experienced in very different ways.
and unforeseen legal issue has emerged following the
enactment of the Family Law Reform Act 1987, whose
effect is that if a married woman plans to become a
surrogate mother by means of artificial insemination, and
with her husband's consent, her husband will become the
legal father of the child. * (In Scotland, where the Act docs
not apply, the child would be regarded as illegitimate.)
It is possible that a form ofsurrogacy involving IVF might
be enforceable, whereby the fertilized egg of another
woman is implanted in the womb of a surrogate-a curious
commentary on how the intervention of doctors via tech
nology appears more acceptable even than loving and non
commercial arrangements between people.*’ The first
such recorded gestures are documented in the Old Testa
When I found out I was pregnant, I danced
around the house. My pregnancy was an easy one.
. . . My body was slowly and pleasantly changing.
Because it was a conscious and well-thought-out
decision to have a child, I felt free to revel in my
pregnancy and motherhood. It was a special time.
I mention all of this because having a miscarriage
has to do with the loss of something so deeply
ingrained for so long that it is partially by
understanding the depth of the joy that one can
understand the depth of the loss.
.Pj'
ment of the Bible: i lagar bore Abraham's child, so that he
The medical term for miscarriage before twenty-six
and his ‘barren’ wife Sarah could have one; Rachel and
weeks is spontaneous abortion. You may experience a
Jacob brought up a child whose surrogate mother was
Bilhah (though in this latter case Bilhah may or may not
have been willing - to have intercourse or a baby). Sur
rogacy is indeed a traditional practice among families in
many parts of the world, particularly between relatives,
including parts of the UK.33 The legal status of all such
threatened abortion beforehand, with cramps and bleeding
or staining. Often bed rest is advised (though there is very
little evidence that it makes any difference, apart from
calming you down), and your doctor may order specific
blood tests to check your hormone levels. In inevitable
abortion, bleeding becomes heavy, cramps increase and
children, however, is illegitimate.
the cervix may begin to dilate. The fetus, amniotic sac and
placenta, along with a lot of blood, may be expelled
completely intact. You’ll probably know when this is
T here has been a recent outcry against surrogacy. It has
to an extent been echoed by some feminist opinion -
although the outcry has been dominated by precisely the
happening. If you are not in hospital, you must do the
sorts of people who seek to curtail women making decisions
difficult task of collecting fetus and afterbirth, putting them
about our own bodies in other spheres. Aside from the legal
in a clean container and taking them to your doctor or
hospital so that they can be examined. Some doctors do not
issues, there are immense social, political and psychologi
cal issues surrounding surrogate motherhood, and femin
ists have only begun to get to grips with them. For the
debate so far, sec Rita Arditti ct al, lest Tube Women and
the Wl IRR1C newsletter (sec Resources).
MISCARRIAGE
(NATURAL ABORTION)!
It is a surprising statistic that in women who know they arc
* If she becomes pregnant under different circumstances - e.g. by intercoursethen the Act does nut apply.
**Al lli< Iiiiic <>l willing, W'lIKKK: li.is Ini n tonl.itlcd bv scvci.il woiiicn
llitcicslcd in acting a\ snuwg.ilcs onl <>l love l<» liicnds ni icl.ilivcs iin.iblc to
have babies llicinsclvcs.
IA inmaiii.igc is ollcn iclcncd Io as an aboilion
llms (onliismgh. and
Miniclinics disliussingly, implying th.il the nnscariiage was dchlicratcly in
consider doing an examination, or only if you’ve had
several miscarriages. Since an examination may yield
important information as to why you miscarried, you may
want to press for this. Ask that specialized as well as routine
tests be done, such as cultures for infection and genetic
examination of tissues. If tests show you have lost a
‘blighted pregnancy’ (where egg and sperm together have
failed to divide correctly) then you can try to be more at
case, knowing that this has been a random event and that
the chances of it happening again are small. If a study of the
fetal tissue shows genetic abnormalities or suggests that you
had an illness or infection, you can work with your doctor
on how to proceed, if the fetal tissue is normal, you may
learn that your hormone levels were insufficient or that a
weak cervix was the problem. Both of these conditions may
be treatable.
An incomplete abortion means that only part of the
‘products of conception* has been |)asscd. Part remains
within, and bleeding will continue. Usually a doctor will
do a dilatation and curettage (I) & C) to clean out your
uterus so that it will heal. A complete abortion mLins that
duced. Wc piclci (lie Icmi mist aiiiagc, bill wc do have Io use lhe let him al
everything in your uterus has l>ccn expelled. You will
tcim on occasions
continue to bleed, but less and less. If you think you are
I
I
438 CHILDBEARING
It is your right to learn as much as possible about your
miscarriage.
.
. ....
One miscarriage docs not mean you aie mien Ic. I here
Successful
is p 70 per cent chance that you will have a
even
after
two
miscarriages.
However,
if you
pregnancy <
Io
have two or more in a mw you may want I begin
investigating. Try to find a doctor who specializes, or is
interested, in the problem (the Miscarriage Association
l lccclihg too long, consult your doctor. (Perhaps a D & C
may be necessary after all.)
During a miscarriage, you may not believe what is
happening. Feelings of helplessness may develop as crampi ng and bleeding increase. Many women fear that they may
bleed to death. Having Io go Io hospital may intensify your
mxiety and fear.
\V<»
holin' /ioiii i/ie hosliihtl do.red iin<l lin'd I
was weak and enormously sad. 1 don't know that
I've ever experienced such deep emotional pain.
The loss was so great and so complete in the way
that only death is. For the first few days 1 couldn t
talk to anyone, but at the same time it was
painful to be alone. I would just cry and cry
without stopping. One of the clearest reminders
that I was no longer pregnant were all the speedy
changes my body went through. Within two days
my breasts, which had grown quite swollen, were
back to their normal size. My stomach, which had
grown hard, was now soft again. My body was no
longer preparing for the birth of a child. It was
simple and blatant. Tiredness was replaced with
weakness. And then there was the bleeding. My
body would not let me forget. I knew things would
improve once we could make love again and would
be even better when we were full of hope. But it
seemed so far away.
l< <Mll
I,,, able Io help) flan with vmii doi lol I" << ||l'<
■
i,
ilH
lull
each detail ol yom nvxl pivguaiicy as il piogicssrs,
for'any spoiling or craiii|A, definik
ing possible reasons f....... 7
ways to deal with contingencies, tests to be nu de as they
• become necessary and so forth. You will need <|ncourageincnt in this project from your partner (if you save one),
family, friends and/or a support group, possibly one geared
to childbearing problems.
The time following a miscarriage is difficult. I hysically,
;;7ull
your body may
still ftd
feel pregnant for aa while,
while, your
your lueasls
breasts
full and tender, your stomach enlarged. You may continue’
■cvcral weeks. If you have iucrcaied flow or
spotting for s<-----odd- or foul-smelling discharge or a high tcinpcralure,
contact your doctor, as you may have an infection which
should be treated immediately. It is usually safe to have
sexual intercourse after four to six weeks when your cervix is
closed and there is less risk of infection.
You will almost always feel grief and anger. You will >
You may also experience a missed abortion. In this case,
a fetus dies in the uterus but is not expelled. It can remain
within for several months. Signs arc lack of menstrual
periods coupled with cessation of signs of pregnancy;
sometimes there is spotting. If it is not eventually expelled
spontaneously, the fetus must be removed with a D & C or
induced labour - a procedure which will be very hard to
accept emotionally.
.
Some possible causes for miscarriage arc structural problems of the uterus, infection, weak cervical muscles,
hormonal imbalances, environmental and mdustnal tox
ins. According to Dr lan Murray-Lyon of Charing Cross
Hospital, drinking alcohol during pregnancy (more than
ten units a week) has been shown to increase the nsk o
miscarriage. Genetic error is associated with a high number
of early miscarriages, and blood incompatibility between a
mother who is Rh negative and the fetus who is Rh positive
can also lead to miscarriage. If you arc Rh negative it is
very important to ensure that the drug Anti D .s given .f you
bleed at alltduring pregnancy to prevent tins reaction and
safeguard futurb pregnancies. Some doctors recommend
AnHD daily throughout the period of bleeding (sec Chapter
18, p. 343).
f |
Try to learn why you had a miscarriage. Some of the
diagnostic procedures outlined above for infert.hty wd be
u'scful here. Ask to sec the pathology report, and ask that a
terminology be explained fully. If you are not saUsficd with
the explanation, ask if there arc filher tests that can be done.
need family and/or friends.
■'
Most people didn't know how to give me support,
and perhaps I didn’t really know how to ask for it.
People were more comfortable talking about the
physical and not the emotional side of miscarriage.
I needed to talk about both. It was also difficult
for my husband, because people could at least ask
how my body was doing. Unfortunately, le would
sometimes be completely bypassed when someone
called to talk with us, despite the fact that he, too,
was in deep emotional pain.
Peelings of grief arc often complicated by g lilt. This can
cause tension between partners. You may wonder if either
of you did something 'wrong’ (too much aetiv ty, loo much
----------is
sex, but neither is known to cause miscarriage,, so
so blame
while,
inappropriate). Dispelling the tension will take a winle,
longer for some than for others. It is best if yor acknowledge
and talk out your feelings. The effects of tl c miscarnage
can last for months. On the date when the ba >y would have
been born, there is usually a resurgence of grief.
If you experience more than one miscaniagc, you will
need compassion and understanding of the losses you have
experienced, and of bow very precious the e pregnancies
were to you. Unfortunately, doctors who can offer this arc
raic. Your helplessness and hopelessness i lay increase
increase if
i
you begin or return Io treatments for your infertility and
start working on becoming pregnant again
1'or further help and support, sec Rcsot recs.
I
I
INFERTILITY AND PREGNANCY LOSS 439
FEELINGS WHEN THE
BABY DIES
The death of your baby - cither at bii th or soon afterwards is utterly devastating. As well as the emotional pain is the
physical pain-a constant reminder of the loss. In fact, your
body knows notl.ing about the baby's death; your breasts are
filled with milk, never lobe used. You will require help and
care on every level at this lime: physical, emotional,
practical and spiritual.
If the baby’s death tikes place before delivery, maximum
pain relief and delivery in the quickest and least hazardous
way arc desirable. You should have the chance to decide if
and when you want to go into labour spontaneously. Your
partner if you have one should be present as long as cither of
you wish. Once the baby is delivered, many women find it
helpful to spend time with it, touching and holding it.
That was all I saw of him; the soles of his feel
when he was born and then the lop of his head.
They brought him to me all wrapped up, even his
face was covered. I didn I know if I could unwrap
him or not. If I'd known he was only going to live
two hours, I'd have unwrapped him and held him
next to me all that time. They tell me he had arms
and legs, but I don't really know because I didn't
see.
I was gently coaxed into holding him, and my
initial revulsion disappeared. I ime passed all too
quickly and allowing him to he taken away to the
mortuary was the hardest thing I had to do.
Many hospitals now provide photographs, which can he
a godsend later.
The photographs and slides have been a great
source of comfort to us, and to our parents.
You should be put in a room away from the nursery and
hospital personnel should he told that you have lost your
baby. Above all, you and your family must be allowed your
grief, in privacy if you need and want it.
You might need to withdraw at first and not confront the
• reality which may be loo much to bear. I here might be a
period of numbness. If you ask for help in grieving, we hope
it will be intelligently and humanely extended. Platitudes
such as, - You’ll have another baby before you know it', or,
‘Think of your wonderful children at home’, have no place.
The death of this particular child is being experienced - no
other actual or potential children have any relevance to the
situation. Perhaps the best help others can offer is sympa
thetic listening and close physical comforting. And we can
often need a lol of listening to, even for months afterwards.
/ developed an incsislible utge Io dexenbe om
ordeal in minute detail to anyone who would listen
and have since discovered that this is a common
reaction.
Since the last edition of (his book, hospitals have begun
to improve in terms of their ability to respond to the death of
a baby. But maternity units arc geared to producing life,
and unless staff arc given help to cope with their own
feelings about the death of a baby, they can be of little help
to us. They may have a strong tendency to prescribe routine
sedatives, yet such drugs can interfere with our ability to
grieve - and grieving at this time is as necessary as
breathing.
,
While procedures for registering stillbirths have been
made easier, there are more improvements we can press for:
more sensitivity during the time we have to make decisions
about burial, and more care to ensure for example that we
are not put near mothers and/or their babies.
It is important to understand if possible why the baby
died. Most likely whatever happened was totally beyond
anyone’s control, but if you suspect negligence, you should
seek legal advice quickly so that the facts can be analysed.
AIMS could probably help you with tl^is (sec p. 44^).
It can take a long time to get over the ddath of a child.
Feelings of guilt or shame are not uncommon. Be prepared
for this and, if possible, make contact with people who will
understand the problems you arc facing. Compassionate
Friends (see p. 442) is a national network of people who
have lost a child. It is a non-religious society. By contacting
them we can give and/or receive much-needed help. 1 he
society acts as a twenty-four-hour service for bereaved
parents, however long ago the death occurred, as well as a
pressure group to urge research into children s diseases.
Nobody wants to deal with death, especially when
your friends are at the childbearing age themselves
and can't help being afraid of you for what you
stand for. I found that my friends wanted me to
pretend nothing had happened. I don't think it
was just my particular friends - it's natural to
want to avoid those things. A.nd so my fantastic
pregnancy, in which a lot of things went on in my
head and hxly that helped me to change and get
myself together, had to be buried. Even now, after
a year, I can see their pain and fear for me as I
start into my eighth month of pregnancy with my
second child. I have to be the one who keeps them
calm, and I especially must assure everyone that
this one will be OK.
ECTOPIC (MISPLACED)
PREGNANCY
Whether we intend to get pregnant or not, it is always
possible to develop an ectopic pregnancy. Such a pregnancy
is dangcious. I here is a danger of severe blood loss, shock,
and even death unless appropriate medical attention is1
.<).
ia :
440 CHILDBEARING
■
given (see below). If your blood group is Rhesus negative,
you will need injections of Anti D, as for miscarriage (see
P
fertilization of the egg by the sperm almost always
occurs in the fallopian tube. If the function of the tube is
impaired in any way, for example by pelvic inflammatory
disease, then it is possible that the fertilized egg might
attach itself to part of the tube instead of proceeding on into
the uterus. This results in an ectopic pregnancy; more
rarely an ectopic pregnancy can begin to grow in the
Jlxlominal cavity, the ovary or the cervix.
Between 5 and 10 per cent of women who have had
previous tubal surgery may experience ectopic pregnancy,
but it can happen to any woman. Ectopic pregnancies arcon the rise because of the increased incidence of 1’ID and
use of IUDs, which can result in scar formation on the
tubes or inflammation of the uterine lining, which then
resists’ implantation of the fertilized egg. If you re of
Childbearing age, have had intercourse and feel constant
abdominal pains you don’t understand, it’s possible you
lave an ectopic pregnancy.
Because all the hormonal changes arc similar to those ot
r normal early pregnancy, you can have all the early signs
of pregnancy, such as fatigue, nausea, missed period and
breast tenderness. As the pregnancy progresses, causing
pressure in the tube, symptoms such as stabbing pain,
cramps or a dull ache may become severe. In addition, you
may or may not have menstrual-type bleeding. To diagnose
an ectopic pregnancy, an ultrasound is needed and/or a
beta blood test can be done to pick up levels of HCG in ttic
blood. If levels arc low, an ectopic pregnancy should be
suspected.
If an ectopic pregnancy is misdiagnosed and the tube
ruptures, you will need emergency treatment m a hospital.
If you have severe pain, it may be better to go straight to a
casualty department than wait to go through your GP. You
may need an emergency operation.
It should be stressed that an ectopic pregnancy can be
vety hard to diagnose. You may need to be persistent.
I kept on going to my GP with various symptoms
and was told it’s an early miscarriage, all m my
min^l, etc. This went on for a month, until 1 was
admilled to hoafdtal w ith severe pain, and even
then was only operated on four days later!
Ectopic
Ectopic pregnancy
pregnancy is sometimes misdiagnosci as an
early spontaneous abortion. It is essential that any tissue
passed from the uterus be checked for developing fetal
tissue.
If the doctor detects an ectopic pregnancy early euou^i,
s/he may be able to remove the pregnancy and save the
I.. .
time
tube. In some eases it is necessary to remove the
t..~ wh^lc
•and/or the adjacent ovary. Careful surgical tech liquc is
important; the less bleeding and consequent ndhesi >ns and
scar tissue, the Ixrtlci the chance for a normal pregnancy
later. In any ease, if you have already had a tub il preg
nancy, there is a higher risk of having another.
The outlook for future pregnancies is somewhat c hanged
by this experience: you may feel depressed and frightened
by the possibility that this could happen again. In a kiition,
khbon,
if the pregnancy was wanted, you arc likely to feel all the
feelings that result from a miscarriage. In a future preg
nancy it may be worth asking for a very early scan.
POSTSCRIPT
hope that this chapter provides help and support for
Wc
who have experienced infertility or pregna icy loss.
women
Yet while medical approaches may develop and change, we
can never assume that they can solve all our problc ns.'I'his
is an uncomfortable fact of life that we arc not hcljxfd to face
fail to disabuse us of
by medical professionals who so often
c.._..........
the myths that they themselves have created, In faet, the
medical profession can neither cure Ilife’s problems, nor
can it cure many medical
i--------- ones. By stimulating awareness
on this point, we can contribute to creating; a more hopeful
lach to infertility and pregnancy loss, to life and death.
approt-..-------,
.
• the
' fundamenta
' *
‘ i issue of
If we tackle this issue alongside
women’s role in society, then women in the futuire will be
tetter equipped to face infertility and pregnancy loss, and
icloudcjd by the
other devastating events in our lives, un.
belief that only medicine can heal the pain with which we
have teen confronted.
tation of Stress in Infertile Couples’. I’a|x r presented Io a cOllklCIKC III
NOTES
1 MOW Baker ct al. Testicular Vein Ligation and Fertility in Men
with Varicolcs’. Hrilish Medical foumal, 14 Dcec.nlxr 1985. p. 1678.
2. M. P. Vessey ct al. ‘Return of Fertility after Discontinuation ot Oral
Contraceptives: Influence of Age and
i.---- Parity’, liritish Journal of l-'amily
i Planning, vol. II, 1986, p. 120.
3. D. Schwartz cl al.
England Journal of Medicine, no. 306, 1982,
?4 *P4 Daniels and K. Weingarten. Sooner or l^ler: the Timing of
Parenthood in Adult Liver.. New York: W. W. Norton 1982.
5 M.G. Ihdl ctal.T/relxincd, 4 August 1984, p. 245
6. Francesca I’urner. ‘Give Me the Moonlight’. Guardian. 14 June
1986.
7. M. and R. O’Moore. ‘Investigations ;iii<rricaliH<nls in the Manifes-
Beijing, 1985.
.
8. See Jill Rakusen and Nick Davidson. Gul of Our Hands, bnidon
Pan, 1982.
,
9. J.L. Treasure ct al. The l-ancet. 21 and 28 Ik-ceinbcr I
P B79.
3.
no. 2.
10. ). Piesse. International Clinical Nutrition Review, vo
11. GJIossc ct al. ‘Effects of Age. Cigarette Smoking and (
on Fertilits Findings in a ILirgc Prospective Study’, BnbsA Medical
Journal. 8 June 1985, p 1697
12. See, for example. J I’ P I sler cl al. I low Rcprcscnlat.se arc Semen
Samples?’ The lancet. 22 January 1983. p. 191
B. Naomi I’fcffcr and Anne Woollelt The Tolxnence <7 Inlerhhly.
Ixmdon: Virago Press. I*>S3. p |03
|4 J. A. Collins ct al I ualnicnl «li |xn<lcnl I’icgii.mcs am im; lnf< rlilv
INFERTILITY AND PREGNANCY LOSS 441
them women and feminists - spent several days discussing women's
Couples', New England Journal of Medicine,
17 November 1983,
I 5.1 a" Penumlm. 'h Diagnostic Ultrasound Safe During I’eriovulatory
reproductive health issues.
*
Houghton. Diane and Peter. Coping with Childlessness. London. Unwin,
1984. By the funders of NAC (sec Organizations, below)
Period?’ Research in Reproduction, vol. 17, no. 2, April 1985.
16. P. Mason et al.
Includes
chapters on ‘Assisting the healing process’ and ’Being childless in later
Induction of Ovulation with Pulsatile Lutcimsing
Hormone Releasing Hormone’, British Medical Journal, 21 January
life’.
Jones, Maggie. Trying to I lave a Baby? -Overcoming Infertility and Chdd
1984, p. 181.
17. Rakusen and Davidson, op. cit., note 8.
18. Craft et al. Thelxincet, 31 March 1984, p. 732.
19. Sec Rakusen and Davidson, op. cit., note 8, p. 108; W D A. Pore
Loss. London: Sheldon Press, 1984.
Overall. Christine. Ethics and Human Repnxlaction: A Femm.st
andK. E. T. Lillie. The I aiivct, I I November 1981, P- I 107; I. Melamed
Analysis. Ixmdon: Allen & Unwin. 1987.
Piercy, Marge. Woman on the Edge of Time. A feminist novel that
envisions a world where reproductive technology exists for the benefit ot
cl al. New England lournal of Medicine, 23 September 1982, p. 820 (this
last report tentatively implicated Pergonal as well).
2(1. ‘Clinical Status of IVF, GIFT, and Related Techniques,
I he
women. London: Women’s Press, 1979.
Rich, Adrienne. Of Woman Born. London: Virago Press,
97/. A
moving and inspiring book that recognizes patriarchal control,of our
Ixmcet, 24 October 1987, p. 945.
.
,
21. See e g. R T. O’Shea et al.. ‘Endometriosis and Fertilisation , 1 he
reproductive capacity and of our attitudes to it.
Stanworth, Michelle (cd.). Reproductive Technologiesr Gender Mother
Ixmcet, 28 September 1985, p. 723.
22. M.G.R. Hull et al. ‘Human In-vitro Fertilisation, In-vivo Sperm
hood and Medicine. Oxford: Polity Press, 1988. A collection of feminist
Penetration of Cervical Mucus, and Unexplained Infertility’, The Lancet,
4 August 1984, p. 245.
23 J 1 Yovich et al. ‘Treatment of Male Infertility by In-vitro Fertilisa
tion’, The Lancet. 21 July 1984. p. 169: J. Cohen et al. Application of In-
writings taking a different view from Arditti et al.
INFERTILITY (see also GENERAL, above)
First Report of the Voluntary Licensing Authority for Human In Vitro
vitro Fertilisation in Cases of a Poor Post-coital lest. Hie Dmcet. 8
Fertilisation and Embryology. London: MRC, 1986.
Harrison, R.F. et al. ‘Stress in Infertile Couples’, in R. F. Harrison et al.
Scptcmlx.r 1984, p. 583.
24. For example, R.G. Edwards and P.O. Steptoe. ‘Current Status of In-
(cds), Fertility and Sterility. Lancaster: MTP Press, 1984.
vitro Fertilisation and Implantation of Human Embryos’, I he Lancet, 3
December 1983, p. 1265; and C. Wood et al. ’Clinical Implications of
Developments of In-vitro Fertilisation’. British Medical Journal,
13
Hull
M.C.R. et al. ’Population Study of Causes, Treatment and
Outcome of Infertility’. British Medical Journal, 14 December 1985,
Kelm9,|«i Anderson. Women's Ailments. Wellingborough, Northants:
October 1984 p. 978. In ar. unusual reference to actual birth-rates, a
lancet leader,' op. cit., note 20, suggests that at best, birth-rates of only
one in five or six per treatment cycle can be expected. Since no reference is
given for these figures, even these should probably lx- treated with
scepticism. And in a recent editorial in Fertility and Sterility authors; were
actually asked to ’be honest with one another’! (M R. Soules.
I he In
Thorsons, 1973.
Pfeffer, Naomi and Anne Woollctt. The Experience of Infertility. London.
Virago Press, 1983. A very thoughtful and helpful guide; a must.
Pfeffer. Naomi and Allison Quick. Infertility Services - A Desperate Case.
London: Greater London Association of Community Health Councils,
Vitro Fertilization Pregnancy Rale: I .cfs Be Honest with One Another,
1988
Rakusen Jill and Nick Davidson. Out of Our Hands: What Technology
Fertility and Sterility, vol. 43, 1985, p. 511.)
25. Report of the Committee of ln<|uiiy into Human Fertilisation and
Docs to Pregnancy. London: Pan, 1982. Contains chapters on mferfihly
Embryology (the Warnock Report), (amid 9314. I .ondon: I IMS<). 1984.
26. From Maggie Jones. Trying to I lave a Baby? Overcoming Infertility
testinp ami treatments, plus information on the effects of drugs.
Winstun. Robert. Infertility: A Sympathetic Approach. Umdon: Martin
Dimitz, 1986. Useful on the Mtbjcct of surgery among other things.
and Child h>ss. I .ondon: Sheldon I'ivss, 1984.
2.7. Ibid.
28. ‘Whither Human Donor Insemination in Britain?
I he Dmcet, 6
March 1982.
29. E.A. Mel-mghlin cl al. ‘Use of Home Insemination in Programmes
of Artificial Insemination with Donor Semen’, British Medical lournal.
15 October 1983, p. 1110.
30. From Barbara E. Mcnning. ’Donor Insemination: the Psychosocial
Issues', Contemporary Ob/Gyn, October 1981.
31. Francic I Imnslein. Children by Donor Insemination: a New Choice
ALTERNATIVE INSEMINATION
Bcrer, Marge. Donor Insemination, available from WHRRIC.
Case Conference, “Lesbian Couples: Should Help Extend to AID?”
lournal of Medical Ethics, vol. 4, 1978, pp. 91-5.
Feminist Self Insemination Croup. Self Insemination (1980). no longer m
print, but on file at WHRRIC and Feminist Library.
Ilomstein, Francic. Children by Donor Insemination: a New Choice for
for Lesbians’, in Rita Arditti et al. (cds), lest Tube Women: What Future
Ixsbians’, in Arditti, Test Tube Women - see General, above.
Klein. Renata Duelli. 'Doing it Ourselves: Self Insemination’, in Arditti.
Motherhood? Lamdon: Pandora Press, 1984.
Test Tube Women - see General, above.
32. Ibid.
t
33. Asa Royal Society of Medicine meeting was told recently, ‘It happens
every day in Rochdale.’
Saffron, lasa. Getting Pregnant Our Own Way - a Guide to Alternative
Insemination, 1986 (available from WHRRIC).
Snowden, Robert and C.D. Mitchell. The Artificial Family - a Con
sideration of Artificial Insemination by Donor. London: Allen and
Unw in. 1981. Considers social and legal issues prior to any changes in the
RESOURCES
PUBLICATIONS
current law. Attempts to be liberal. See also The Experience of Infertility
and ()ut of( )ur I lands in General, alxrvc, Ixith of which contain sections
mi AID.
I.I.NI-.K Al.
Arditti, Rita et al. (uds). Test Tube Women: What Future Motherhood?
London: Pandora Press, 1984. An inlcrmilional collection of feminist
writings, mostly very critical of technological development.
Dowrick, Stephanie and Sybil < Jriindhcrg (cds). Why (Mlren? I .ondon:
Women's Press,
1980. Invaluable collection of writings by eighteen
women, each taiking abotil her frdings/d< cidons/non d< <-isioirs
H.Ji.ha. H.bii I*
<1 d
l.d-.l
Ho < n-./.-H, M.nl. « lol.l:
W-.n. ..
llculeod Pus/a-. tncs < .hllon, NJ I him.m.i I’ksa. I'Ml P.iiI ..I a hso
volume collection th.it came out of a mreling in which coummmly
woikcis, do. Ims, s< ii iilrh. < lhi< isls ami govciiiim iil plamieis
most ol
FOSTERING AND ADOPTION
1984-5 (Ixxiklct
Aduptiim a Child,
available
from
BAA!',
see
()fg.iiii/ali<ms).
.......
..... .I’ind me a Family - the Story of Parent* for Children.
Argent.
Ilcdi.
H.n.h.n: Souvenir Picas. I'H4 A must for jx-oplc coiiMrlcring a<lo|>ling
'■.|>< l l.ll IM < >1* • llll'lo O
Rowe, |.rnc.
m the i.uihtie*. HiimIoii: BAAT. 1983.
Rowe, |.nie. Yours by C.hoit c hinilon Koulkilgc ami Keg.ni P.ml. 1982
A guide Io llic adoption pnx ess
442 CHILDBEARING
11
miscarriage and stillbirth
Borg Susan and Judith Lasker. When Pregnancy Fails: Families Cobing
with Miscarriage, Stillbirth and Infant Death. London: Routledge and
Kegan laul, 1982. A sensitive and helpful book, though American for
anyone who has been through the tragedy of their child’s death.
Leroy, Margaret. Miscarriage. London: Optima, 1987. Based on the
experiences of the Miscarriage Association.
National Childbirth Trust. Miscarriage (leaflet available from the NCI’
see Organizations).
’
Oakley, Ann, Ann McPherson and Helen Roberts. Miscarriage.
London, Fontana, 1983. A helpful book that looks at causes and treatment
and women’s experiences.
Standish, Liz. The Loss of a Baby’, The Lancet, 13 March 1982, p. 611.
ORGANIZATIONS
GENERAL
Association for Improvements in the Maternity Services (AIMS) 40
Kingswood Avenue, London NW6 6LS
British Organization of Non-parents (BON), BM Box 5866, London
WC1N 3XX. Support group for those who believe that being child-free
shoidd be a seriously respected option in society.
British Pregnancy Advisory Service, head office: Austy Manor, Woolton
Wawen, Solihull, West Midlands B95 6BX. Tel: 05642-3225. Has
branches in many parts of the country - see Resources in Chapter 16 or
your local phone book. A charity that can help with Al, infertility testing,
Child, 367 Wandsworth Road, London SW8 2JJ. I’d: 01-486 4289.
Supports infertile people through support groups, telephone counselling,
National Association for the Childless, Birmingham Settlement, 318
Summer Lane, Birmingham B19 3RL. A self-help organization,
registered as a charity, offering advice, information and support to people
experiencing infertility. Tends to be orientated towards heterosexual
couples, but has about 100 contacts throughout Britain, and many support
groups. Produces factshccts and an invaluable newsletter, all of which arc
fjee to members. Also holds seminars, c.g. on inter-country adoption.
NAC also aims to improve NHS infertility treatment.
Single and Infertile, 293 Mcadgatc Avenue, Chelmsford, Essex. For both
single men and women who arc infertile.
Womens Health and Reproductive Rights Information Centre
(WHRRIC), 52-5 Featherstone Street, London EC1Y 8RT. Tel: 01-251
6580/6332. Provides information about self-help groups generally and
infertility support groups in particular, as well as general information,
including a^out Al.
alternative insemination
BPAS (British Pregnancy Advisory Service) provides AID (Al) in many
parts of the country and docs not limit their service to heterosexuals or to
couples. Also offers counselling and other services, such as sperm testing
and sperm storage facilities. See General Organizations above for address,
and for other organizations which can advise on availability of AID.
1
I
.
■
■
EOS TERING AND ADOPTION
British Agencies for Adoption and Fostering (BAAI'j, I'.
11 Sonlhwark
Street, London SKI IRQ. Tel: 01-407 8800; Scottish Centra
23 Castle_
..re:_______
Street, Edinburgh El 12 3DM. Tel: 031-225 9285. Has us^hI leaflets lor
prospective adopters, adoptees, .stepchildren and on issues such aschild
from the past*. Very helpfulI on
on adoption
adoption altogelli
altogether.
16
Ground, London SW1 211 \ i c|: (,| -222
2695. Contact Line 01-222 2211. Links parents of childrc
n with special
needs. Runs local groups: national telephone link-up service, Contact
Line.
Family Care, 21 Castle Street, Edinburgh El 12 3DM. Tcl:031 -2256441.
Information and counselling service on all
ail aspects
aspects of
of ad(
acit ption
phon and
-met on
•••
childlessness; also provides social work service for single-p ircnt families
and a befriending scheme.
Jewish Association for Fostering, Adoption and Infertility (JAFA), head
quarters: PO Box 20, Prcstwich, Manchester M25 5BY. 'l ei: 061-773
3148/776-3199. Provides support, advice and assistance, anc
has branches
nation-wide.
Lesbian and Gay Fostering and Adoption Network, c/o London Friend,
86 Caledonian Road, London Nl. Tel: 01-837 3337.
National Poster-Care Association, Francis House, !• r mcis Street
London S W1P IDE. '1 cl: 01 -828 6266. Exists to encourage I igh standards
of foster care and increased opportunities of a foster home for children ‘in
care’.
NORCAP (National Organization for the Reunion of Children and
Parents), 3 New High Street, Hcadington, Oxford OX3 7AJ. II lelps
lelps adult
adult
adopted people who arc trying Io get in touch with their birth parents, and
parents who have given up their children for adoption, as well as adopters.
Send sac for information.
Parents for Children, 222 Camden High Street. London NWI 8QR. Tel:
01-485 7256/7548. Specializes in especially difficult to placcchildrcn and
also ‘unusual’ parents and families, (see 1 ledi Argent’s book above).
Parent to Parent Information on Adoption Services, c/o Lower Boddingtoi\ Daventry, Northamptonshire NN 11 6YB. 'l ei; 0327-60295. A
self-help support and information service for prospective and existing
, adoptive families.
MISCARRIAGE AND STILLBIRTH
I he Compassionate Friends, 6 Denmark Street, Bristol BSl 5DO. l ei:
0272-292778. Helps bereaved parents.
Foundation for the Study of Infant Deaths, 15 Belgrave Suu ire, London
SWI8PS. Tel: 01-235 1721.
Miscarriage Association, I’O Box 24, Ossett, West Yorkshire WF5 9XG
’Pel: 0924-264579.
National Childbirth Trust, Alexandra House, Oldham Terrace, London
W3. lei: 01-221 3833. Can also put women in touch with others who
have experienced miscarriage and who hold regular meetings.
The Stillbirth and Neonatal Death Society (SANDS), 28 Portland Place,
Argyle House, London WIN 4DF.. Tel: 01-436 5881. Ilcips bereaved
parents.
Twins and Multiple Births Association (TAMBRA), Secretary: 41
Fortuna
. ............ Way, Aylesbury
*
"Park, Grimsby, ....................
South I lumberside, DN37 9SJ.
Tel: 0472-8831«2. Support
P ..
’ for
' people who have experienced
networks
death of one or more babies.
: '
Public Policy Division
Voluntary Health Association of India
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