Sexually transmitted infections (STIs) are probably the most tabooed and stigmatized health subject matter known to us, despite their prevalence—one in 25 people globally have at least one. For Ina Park, M.D., M.S., the enduring mystery shrouding STIs represented an opportunity to educate and entertain. Park’s new book, Strange Bedfellows, weaves together science, sexual escapades, historical tales, and humor to tell the hidden stories of everything from human papillomavirus (HPV) and syphilis to chlamydia and herpes.
A fierce, sex-positive advocate for public health, Park got her start as a sexual-health peer educator while attending University of California-Berkeley. She more than once dressed as a giant condom that handed out condoms and counseled students after a STI diagnosis. Park is now an associate professor at the University of California San Francisco School of Medicine, and also serves as the medical director of the California Prevention Training Center and a medical consultant for the Division of STD Prevention at the Centers for Disease Control and Prevention (CDC). In conversation with Terri Wilder, Park deconstructs herpes stigma, STI contact tracing, the myth of “no penis equals no risk,” and much more.
Turning STI Fear Into Fascination
Terri Wilder: First of all, congratulations on your new book. I have found myself both fascinated by the history of sexually transmitted infections and completely entertained by the way you have delivered the information. How did you come up with the idea for this book?
Ina Park: Well, I’ve done my job right if you were entertained. My primary goal with the book was to entertain folks and get them informed, and laugh and learn at the same time.
I had been in the field of STI/public health research and practice, because I practiced in a sexual health clinic for about eight years. What I was observing was that STI rates were continuing to climb and, meanwhile, the stigma around them hadn’t budged at all. When I was giving those diagnoses to my patients, they were still feeling ashamed and stigmatized. I said, “What can I do as an individual to potentially put a dent in this?” I can’t step into everybody’s bedroom when they’re about to have sex and say, “Wait a second. Use a barrier!” So I can’t control what people do, and I can’t control STI rates that way.
Then I said, “Maybe there is something I could do to help combat the stigma that is still confronting these infections. And to do that, I’m going to have to change folks’ attitude from one of being scared.” When we have fear of an idea or a concept, we want to sort of run away from it. I needed to turn that fear into something like interest or fascination. To do that, I wanted to tell some stories and do them with humor, and see if I could draw people towards the topic.
I never would have chosen to write a book. The prudent thing to do would have been to start writing some articles, perhaps, and shorter-form pieces. But something happened which sort of pushed me to do this—my son was in a car accident. When I was in the hospital with him, I just felt like, wow, he got hit by a car, and I could get hit by a car, or struck by lightning. Maybe I should actually take some time and write this book now, when I still have all the ideas fresh in my mind.
Wilder: You shared the story of your son’s hospitalization. Would you mind retelling a couple of stories from his interactions with his medical providers?
Park: Absolutely. My son was hit by a car in 2015. He sustained a small skull fracture and a pretty complicated fracture of the femur. We were in the intensive care unit, because he was being evaluated in case there might have been a bleed in the brain.
The next day, the neurosurgeon came by on his rounds. They checked his mental status by asking him his name and where he went to school. My son sort of interrupted the team who was assessing him and asked the neurosurgeon, “Hey, have you ever had herpes? Because you should ask my mom. She knows everything about it.” The whole team just erupted in laughter. The neurosurgeon started laughing and said, “Well, I think this kid is clear neurologically.”
That was just the beginning of the string of questions that came from my son to basically every health professional he interacted with. He would ask them about whether or not they were having sex, and whether or not they’d had an STI. He asked the orthopedic surgeon whether or not he’d had syphilis. He asked the ICU nurse about HIV. He asked this chaplain whether or not he’d ever had chlamydia.
So, I spent most of the hospitalization with my head buried in between my hands, just dying of embarrassment. But I had a moment where I looked at him and I said, “This kid does not realize that he should feel uncomfortable about these topics because he has grown up observing myself and my husband—who’s a colorectal surgeon—so everything in our house is sort of below the waist, in terms of topics. He is just very comfortable with the idea that people have sex, that it’s a normal part of human development, and that STIs and HIV can come along with that.
And I said, “You know, maybe I could do something to get people a little bit more comfortable. Not as comfortable maybe as this 7 year old who’s been raised with this content his whole life. But perhaps by sharing my own stories and some of the really fascinating science, I could get people more interested in the topic and maybe get them a little bit more comfortable in talking about it.”
Why Herpes Is Still Incredibly Stigmatized
Wilder: On the cover of your book is a picture of a bed with two pillows, and the sheets look all crumpled. There’s a big red crab doll sticking out of the bedsheets. So, you have even inserted humor into the cover of your book.
Park: Right. We want people to know just from looking at it that, “Hey, this is a book about STDs.” You can already tell that we’re not going to take ourselves too seriously, and that we’re going to try to infuse humor throughout the book—which is certainly something I attempted to do.
Wilder: In the first chapter in the book, you talk a great deal about herpes and stigma, in particular. Why would you spend so much time talking about stigma with this particular STI?
Park: It’s because it is the last stand, in terms of my patients and their reactions to receiving an STI diagnosis. I feel like we’ve gotten to the point where people can sort of shrug off the diagnosis of chlamydia or gonorrhea or syphilis. These are bacterial infections that you can treat pretty easily with antibiotics.
But when you give someone a herpes diagnosis, it can be devastating—even though, for the most part, most people after the first year or two will have very mild symptoms. And some have no symptoms at all. And yet people feel incredibly stigmatized, still, by this infection.
So, I wanted to talk a little bit about the history of the stigma. I wanted to talk and try to normalize the fact that so many of us—one in eight—actually have antibodies to herpes simplex virus type 2, and just let people understand that these are incredibly common infections and, for the most part, over time people will come to a place where it is a part of their lives but not really the biggest issue.
I took pains to highlight the case of someone who I know now who is dating with herpes, now in her 50s, and it’s become much less of a deal than it was when she was in her 20s and having to disclose her status to partners.
Wilder: What is the origin around stigma related to herpes?
Park: It’s interesting because one of the myths that’s been circulating around in my community was that the company that developed acyclovir, which is one of the medications used to control herpes, actually manufactured the stigma because of the ads that they ran. Their ads implied that disclosing herpes is the worst thing you could possibly have to do with a partner. They’ve been accused of manufacturing the stigma—as have publications like Time magazine, who put a cover out in the early ’80s with a blood-red H, and said, “Today’s scarlet letter is the letter H for herpes.”
The truth is, though, in speaking to the researchers who actually developed acyclovir who were taking care of patients in the ’60s before there were any treatments, people felt incredibly stigmatized when they had genital herpes prior to any sort of development of drugs. The fact that there are actually medications out there that can, for the most part, control the infection has been great for folks who are living with symptomatic HSV [herpes simplex virus].
Unfortunately there’s been, I think, no dent in the stigma associated with this. Can I just share a story?
Wilder: Yes. Go for it.
Park: I have a patient who’s been living with HIV for more than 20 years. I had to disclose a genital herpes diagnosis to him, and he just started crying. I said, “What’s going on?” And he said, “I don’t know. I didn’t even cry when I was given my HIV diagnosis. Why am I crying now?” I think he felt this burden of having to disclose the diagnosis, and the fear of being rejected. Even though he was taking HIV medications [and] we have this whole concept of U=U, or undetectable equals untransmittable. We don’t have U=U for HSV. I think that’s what we need in order to combat the stigma of this particular infection.
Wilder: In later parts of your book, you talk about the PrEP [pre-exposure prophylaxis] medication Truvada [FTC/tenofovir disoproxil fumarate], which was approved in 2012. You ask: What about prophylaxis for other STIs? When are we going to get to a point where we can offer that in sexual health clinics?
Park: I would love it if we had some sort of PrEP for herpes, or PrEP for STIs. It’s something actually that is being studied. In fact, our clinic is actually doing a clinical trial. There’s a larger clinical trial going on nationally to look at taking doxycycline, for example, in order to prevent an STI. Normally an antibiotic would be given after you’ve already been diagnosed with an STI. The idea for this is to take the antibiotic after sex but before you get diagnosed with an STI to prevent an STI from developing.
It’s controversial because people worry: Well, if you’re going to use antibiotics, is it going to increase community levels of antibiotic resistance? Is it going to make people more inclined to have sex without barriers (which they already are because of things like PrEP)? So there are concerns in the community about whether or not this is a good idea. But obviously the STI epidemic was raging out of control before COVID-19 hit. So we are trying to get creative in the field to see what might work. Perhaps taking antibiotics before you receive a diagnosis of an STI might be one of those methods.
Wilder: Until we actually have a cure for herpes, we definitely need PrEPs and PEPs [post-exposure prophylaxis] for the other sexually transmitted infections.
Park: We do. I would love a stronger antiviral for HSV. I’m not hopeful that we’re going to have an HSV vaccine anytime in the near future. If we had a stronger antiviral that could completely suppress in the way we do with HIV and eliminate the risk of transmission, then I really think that would go a long way in terms of folks feeling more comfortable disclosing. Then they would have a tool to say, “I do have HSV. I’m living with HSV. But I have these antivirals that will completely suppress me.”
The Link Between Pubic Hair Grooming and STIs
Wilder: Let’s talk about your chapter on pubic hair, which I was fascinated by. And I’ll tell you why.
Pubic hair, and hair, in general, has a lot of cultural significance. It is policed. You shared your experience of getting your pubic hair removed while in Brazil—and that there can be some less-than-ideal circumstances that come about from grooming the pubic hair.
Park: I decided to get a Brazilian—for the first and last time—while I was in Brazil. I had been trying to coach patients about pubic hair, because some of them would come in and say, “Oh, I’m sorry I didn’t groom all my pubic hair before I saw you.” I would say, “Listen. Your pubic hair’s the least of my problems.” And I realized: Why are people thinking that pubic hair is the enemy? And why do they feel so compelled to remove it? And I was trying to counsel people that removing all your hair can cause damage to your skin. That can make you more vulnerable to catching skin-related STIs, such as herpes or HPV.
But then I said, “You know, I’m giving all this advice and I really have never done this myself. I probably should put my money where my mouth is. Or put my wax where, I don’t know, put my wax where my mouth is.” I decided to do that.
Everything was fine for like two hours. Then, that evening I looked down at where I’d been waxed, and I just saw so many tears in the skin. I was bleeding. There were bumps. There was inflammation. I thought, “My goodness. If I ended up being with a new partner right now, I would be so vulnerable to catching some sort of skin infection, such as a herpes or HPV.” Then I said, “OK. Well, I’m going to take a deeper dive into pubic hair.” And it turns out one of the studies I quoted was that one in four people in a large national survey who had groomed their pubic hair had sustained an injury at some time. Most of those are nicks and cuts, because shaving is still the most popular way of removing your hair. But something fascinating: One of the trauma surgeons that I spoke with started studying this—he’s a urologic trauma surgeon—and found that around 3% of the emergency room visits for genital issues are related to pubic grooming injuries. He said, “I don’t feel like that’s worth it.” His whole research group has been studying grooming injuries, as well as the association with grooming and STIs.
Wilder: You also shared the story of a person who had HPV who shaved, and then the HPV infection moved to another part of their pubic area and caused a bigger breakout. Can you talk about this cross-potential to infect a person by using a shaving instrument?
Park: Let’s think about it this way. This poor gentleman just had a few warts, and he had them frozen off. He thought everything was fine. But the thing is, there were little, microscopic HPV in the skin and around the hair that he wasn’t aware of. He was about to go on a date, and so, he did a very quick shave. If you could just imagine, it’s like tilling the soil and sprinkling the little seeds of HPV everywhere. It got on the razor. It spread all over his pubis. Then he ended up with, I want to say, at least 15 little warts in the area. To make it worse, the date was no good. He didn’t even have sex with the person. He ended up with a lot of warts and unfortunately had to be referred to a surgeon, because it was too expensive for us to deal with in the outpatient clinic. That’s the thing: These viruses are so small, and any little microtrauma to the skin can allow a portal of entry.
We know this from HIV, as well. When people have sex, they can cause little microtears in the skin of the rectum or in the vagina. That can be a portal of entry for HIV. It’s the same thing with HPV.
Anal Pap Tests, Oral Sex, and Antibiotic-Resistant Gonorrhea
Wilder: Since we’re talking about HPV, can we talk about the importance of anal Paps and the ANCHOR study?
Park: Absolutely. We know that the cervical Pap smear has really been a home run, in terms of cancer prevention, in reducing the number of cases and deaths from cervical cancer. We also know that men who have sex with men who are not living with HIV are about 35 times more likely to get anal cancer than the general population. If you talk about folks living with HIV, we’re talking 70 to 100 times more likely.
The idea is that perhaps if we did an anal Pap test, where we would take a Q-Tip and swab around the anal canal, looking for those precancerous cells, that maybe that’s a good idea, in terms of preventing anal cancer. That’s totally logical, right?
Right now, the standard of scientific evidence that’s required is to change national guidelines to say every person living with HIV should get an anal Pap at a certain age. We didn’t have that kind of evidence, in terms of knowing what an age cutoff should be and whether or not using an anal Pap would actually lead to the detection of precancer, and if treating those precancers actually prevents anal cancer and the complications of anal cancer.
So, Joel Palefsky, who is a researcher at UCSF—who I call the Elvis of anal HPV, because he’s very well known in the field—now has a huge grant from the National Institutes of Health and the National Cancer Institute. It’s called the ANCHOR study, and that is just to look at whether or not anal Paps and treating anal precancer are going to actually prevent new cases of anal cancer in the future.
That study is going to be ongoing for the next two years. When it is finished, we are going to have a lot more information that is going to help guide our national guidelines for anal cancer screening for men who have sex with men.
Wilder: When we talk about sexually transmitted infections academically, it’s very heteronormative, or it’s very focused on men who have sex with men. One of the things that I appreciated about your book is that you talk, in one of your chapters, about STI risks for women who have sex with women. Can you talk about that?
Park: One of the researchers who I interviewed for this section, who’s a dear friend—her name is Jeanne Marrazzo—said, “People just think that no penis equals no risk. That’s simply not true.”
Even women who have had sex with women believe this, to a certain extent. What she has observed in her career is that sometimes women who have sex with women say, “I am not at risk for any of these STIs and, therefore, I’m not going to be screened.” They don’t perceive themselves to be at risk, for example, for cervical cancer or for HPV-related issues. So, they also don’t get screened.
There’s a lack of attendance to STI screening or cancer screening, because of maybe a perceived lesser risk on their part because they’re not having sex with men—and also probably because people feel stigmatized or don’t feel welcome, you know what I mean? They are maybe feeling uncomfortable about actually disclosing the fact that they’re a woman who’s having sex with women.
The truth is—I go into this in my book—that for certain sexually associated infections, such as bacterial vaginosis, women who have sex with women can absolutely share these bacteria with each other. They can also certainly transmit HPV very efficiently from the penetrative acts that they do with fingers or with toys. The same with herpes. It is less likely for a woman having sex with women to be infected with something like gonorrhea or syphilis. Chlamydia, if they’re only having sex with women, is also less likely. But if you’re sharing toys, then certainly you can get a bacterial STI that way.
So, it’s just to counteract that narrative that women who have sex with women do not need screening and therefore providers shouldn’t even ask them if they’re not reporting having sex with men. I want to counteract that narrative, that women who have sex with women should be screened in exactly the same way that women who have sex with men should be screened.
Wilder: You have the chapters on gonorrhea, syphilis, and chlamydia so beautifully laid out. Could you throw out some of the more interesting pieces of information that you uncovered during your research about the history of these? For example, one of the things that stuck out to me was that Hawaii is a port of entry for antibiotic-resistant gonorrhea.
Park: For some reason (we don’t exactly know why), antibiotic resistance of gonorrhea tends to start in Asia, and it has often started in Japan or Southeast Asia, and then comes to Hawaii, then goes to the mainland, to the West Coast, and then spreads to the East Coast. Hawaii has really doubled down in terms of doing surveillance on gonorrhoeae isolates. They test more gonorrhea for antibiotic resistance than any other state in the country. I found their whole program fascinating. When there is going to be an outbreak of antibiotic-resistant gonorrhea, they will see it first.
Another thing that I thought was really interesting about gonorrhea was just the fact that if someone gives oral sex to a male partner, for example, and gonorrhea happens to be deposited at the back of the throat, there are other species in the same classification of [the genus] Neisseria that they can have bacterial sex and actually exchange genes that can give instant antibiotic resistance to the gonorrhea that are sitting there. We do get antibiotic resistance over time. It takes some time because the organism has to be exposed to the antibiotic. But then there’s also this ability for bacteria within your throat to actually exchange genes and have a much more rapid onset of the antibiotic resistance.
So, people probably didn’t think of oral sex. It’s safer sex from an HIV standpoint, but it’s definitely something that fuels antibiotic resistance in a way that people probably didn’t understand.
Tracing Sexual Networks to STI Risks
Wilder: This tangentially reminds me of you talking about sexual networks and why that’s important to public health and sexual health. Why can one person have sex with two people and get a sexually transmitted infection, but another person can have sex with 30 people in a month and not get a sexually transmitted infection—where maybe both people are having barrier-free sex?
Park: I think people do understand this intuitively, that when you’re having sex, you’re not just sleeping with the person sitting in front of you—but in the case of a bacterial STI, let’s just take chlamydia—you’re also sleeping with whoever they’ve slept with in the past two months. It’s possible that they could be harboring an infection from a past relationship. And so, this idea that you’re having sex with every single person this person has had sex with in a certain period of time and you don’t necessarily know how many connections that person might have, or whether the person that they just slept with before you had had many, many partners.
Sexual networks, or this idea of how we connect sexually in space and time to people, is just as important as the absolute number of people that we sleep with. There’s this huge myth out there that if I sleep with a lot of people, I’m more likely to get an STI. An STI is sort of some way of being punished, or whatever, for being a promiscuous person, quote-unquote.
The truth is that you can be in a network that has a lot of infection because of the way the network is structured, and that just having sex with one person in that network can then give you a very high risk of contracting HIV or an STI, depending on what infection we’re talking about.
One of the examples I use in my book was from a study in Colorado Springs, where they found that half of the people with gonorrhea in the city frequented the same six bars and nightclubs. They calculated that if you were to meet a partner at one of these six places, your risk of getting gonorrhea during that time was 300 times higher than if you met someone at a different place in the city. How would you know that? You wouldn’t necessarily know that. There are lots of forces that are outside of your control that may increase your risk of getting an STI that you’re not aware of. And the absolute number of people you sleep with is just one small part of it.
Wilder: Then there are systemic influences on those sexual networks, like: Do the folks in these networks have access to health care? Do they have access to education about sexually transmitted infections? Do they have the fiscal resources to access care? Do they have the support of their peers, in that it is not stigmatizing to get tested and treatment?
Park: Right. It also depends on the size of the community and if you have a very strong preference. Let’s say, if you happen to be a trans person who only wants to have sex with other trans people, the number of folks that are available to you for sexual partnerships is smaller. So, if there are lots of concurrent relationships going on, then your risk of contracting HIV in that network might be different than if you’re in a network where there are very few concurrent relationships going on, and folks are mixing in a different way.
The same thing happens as well for Black men who have sex with men. If folks prefer to date within their race, there are less folks to date, and less folks to have sex with, and the networks are more dense. Therefore, the risk of contracting an STI or HIV can be higher in a small and dense network where people are more interconnected. That’s why, in heterosexual networks, we see greater rates of STIs and HIV in Black women who, for the most part, prefer to date Black men, in certain studies that I’ve read. If there are less Black men in the community who are eligible to have sex with, because some are incarcerated or some are missing due to violence, then, again, the networks become more dense and smaller. You’re more likely to catch an STI in that type of network.
Wilder: In your book, you talk about the ways that people choose sex partners is not random. Can you say more about that?
Park: There are so many things that affect our sex-partner choice. First and foremost, I think there’s who we’re attracted to sexually. There are folks that have very strong preferences based on gender identity. There are people who have strong preferences based on race. Then there are other things that shape that, in terms of who happens to be available to me. So, geography can play a role.
People don’t necessarily think that “the type of person that I’m attracted to may actually play a greater role in my risk of catching an STI.” I don’t want to judge who people like or who they want to sleep with. I want people to understand that having sex in certain networks, with certain types of folks, may be higher risk than having sex in others. That’s not going to change who we are fundamentally attracted to, but it’s something that we need to be aware of, as we’re going out there into the sexual marketplace and dealing with the possibility of contracting STIs or HIV.
COVID-19, Cutting Back on PrEP, and Custom Condoms
Wilder: Have you seen a drop in PrEP use in your practice? I ask because I’ve spoken to gay men, in particular, who’ve told me that they’ve taken a break from PrEP due to COVID-19. And any concern that we may see an increase in HIV diagnosis due to this quote-unquote break?
Park: There are two issues that happened. There were some patients who said, “I’m taking a break because I’m not going to be hooking up, or using Grindr or other sex-seeking apps right now, because I’m just concerned about COVID-19.” So, that happened. Then there were people who were trying to actively access their PrEP and were having difficulties. Lots of clinics had to reduce services—and some of them had to shut down early on in the pandemic. So, there were people that went with a gap in their PrEP prescriptions, those who wanted them. I think both of those things were factors.
I do worry, because accessing care is still challenging, and folks are still afraid to come in for services. It’s getting a little bit better, with the vaccine and the rates going down. But I do worry that folks that experience any barriers to receiving their PrEP are just out there, vulnerable to potentially getting a new HIV infection.
Wilder: I was really fascinated by your writing around condoms. Since PrEP, while we still encourage folks to use condoms, there’s almost been this kind of switch, like, “I have PrEP now.”
You talked about how condoms might be more popular in other countries. And specifically that Japan was the last industrialized nation in the world to legalize the pill, in 1999, which is a little horrifying to me—but that condoms are popular there.
Park: They are. The other even more horrifying thing is that Japan fast-tracked the approval of Viagra in six months. And it took more than 10 years, or decades, to get the pill approved. It just shows you where priorities lie.
For some reason, and probably because of a lack of access to other alternatives, lots of Japanese women—I’m talking about cis, hetero women—actually used condoms as their primary method of birth control. It was like 40%. In the U.S., it’s closer to 10% to 15%.
Condoms are big in Japan. They also have lots of great technology in terms of making condoms very thin. I hear patients say all the time no matter how thin you make it, it’s never the same as going without a condom. I totally appreciate that. But I will say the Japanese have tried to push and innovate in this space because they have lots of condom users in their country.
I also want to say that both the internal condom—which used to be called the female condom but can be used for anal sex or for vaginal sex—and then the external—or the traditional rolled condom—are the only sort of multipurpose prevention technology that we have that can provide contraception and protection from HIV and STIs. But there are some efforts being made to bring new multipurpose prevention technologies to the market, such as vaginal rings that have both contraceptive medication and other medications that would prevent HIV, as well as prevent other STIs. I will be very excited if those end up coming to the market. We’re not quite there yet.
Wilder: I was very interested in what you put in the book about this idea of customized condoms. People complain that, “This doesn’t fit. It’s too restricting.” And you mention custom-fit condoms—up to 60 different sizes—and that custom condoms cost two to three times as much as their standard counterparts. If there is a demand for this, even though in the United States people might not use condoms as much as maybe in Japan, do we think this price point will ever come down? Do people even know that this is available to them?
Park: I don’t think so. I’m using myself as a litmus test, because I do a lot of work in this arena, and I had no idea that this was available. I feel like if there are more competitors in this space then there will be a reduction in price. If there are only a few players, they can sort of charge what they want.
I spend a lot of time below the waist. And I can tell you, people’s penises come in all sorts of shapes and sizes. It is silly to think that one size will fit all when it comes to a condom. I would love to see custom condoms become more affordable and just more prevalent out there.
Wilder: You have a motto: “Have sex with people you like.” It’s so interesting that you talk about that in your book. Because I’ve been thinking about it in my personal life.
Park: I wanted to come up with some sort of advice. I talked about Michael Pollan’s advice, which is: Eat food, not too much, and mostly plants. But I couldn’t directly translate that into the world of sex and STIs.
I also realized that I can’t do anything to prevent folks from actually catching an STI—other than I can encourage people to use barriers and reduce the number of partners and spread them apart in space and time. But the truth is, all of us are going to be exposed to an STI at some point during our sexual lives. And some of us are actually going to be diagnosed.
And so, what can we do to minimize regret? If we’re living in a way that feels authentic and we’re having sex with people that we like and we’re having pleasurable and mutual relationships, if an STI enters the picture, then you can shrug it off a little bit more easily and say, “Oh, well. That’s too bad.” That is as opposed to being devastated, which can happen when people get an STI from someone whose name they can’t remember or they were too intoxicated to remember that the sex was even good, or they actually think the person is a jerk, but they just did it because they were bored. Then when an STI or HIV enters the picture in that scenario, it can be very hard emotionally to recover from.