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It Would be Tricky

What Condoms Are Not Good For

By Robert Kumpel

As venereal diseases continue their rise, young people are told to protect themselves by practicing "safe sex"--which usually means condoms. Yet one disease grows in incidence whether condoms are used or not: The human papilloma virus, commonly known as genital warts.

The papilloma virus lives in skin cells near the genitals as well as in cell linings of genital areas, so even if condoms are used, skin contact between two bodies is all that is needed to transmit the virus. For males, the results are visible -- warts on and around the penis. For females, the results are not always visible and are often undetected until a pap smear. Symptoms frequently recur and the virus is believed to be permanent. If left untreated, the warts will continue to spread. Women face the risk of cervical cancer.

Dr. Gregg Lichtenstein has worked at San Diego State University for 15 years as medical director at student health services. A graduate of Tufts Medical School in Boston, Lichtenstein, 48, treats sexually transmitted diseases, including papilloma: "I see patients part-time, so I probably see about 40 a week. At the health center in general ... It's probably about 1000 per week. I would guess maybe about five percent are for STDs." That's approximately 50 patients per week. Of those patients, nearly half are diagnosed with papilloma. "When you include abnormal pap smears, I would guess about 40 percent."

Lichtenstein describes papilloma as, "A virus that causes warts of different types. There are about 60 different sub-types of wart viruses that people have been able to isolate so far. Some of those viruses cause common warts like you'd see on your fingers or the bottom of your foot. Other wart varieties might cause flat warts like somebody might get on their face. Other ones cause genital infections -- either externally or internally." There are specific types of papilloma, however, that cause genital warts. "Type 16, 18, some of the thirties, those are kind of the dominant ones in terms of more risk for potential malignancies, in terms of cervical cancer."

With papilloma, unlike other venereal diseases, Lichtenstein points out that most clients, especially women, are not aware that there is a problem when they come in. "Men might notice a bump or several bumps on the penis that they hadn't seen before. Women might notice similar types of bumps on the labia, but a lot of the women we're seeing here are being diagnosed on the basis of an abnormality on their pap smear."

Discovery of papilloma is never welcome news. "An occasional student will be extremely upset, then there areother people that will just try to pass it off. We explain to them that we're not sure how long this virus stays around in the body after it's treated. You know, it could conceivably stay there lifelong, although we don't expect symptoms -- pap smear abnormalities--to persist for that length of time. They mainly try to get at who might have infected them. We really can't tell somebody that, because the problem is the latent period. This virus could cause infections to appear months, perhaps even years, after you were initially infected.

"The typical modality for treating warts is some kind of a destructive measure. None of these has shown any particular promise in efficacy above other ones. For small warts it's putting a tiny amount of an acid on the wart, freezing the wart, you can numb up the skin and use electrocautery to burn a wart off. There are prescriptive-type medications that are out there for treating warts now. One's called Amiquimod or Aldara and the other one is called Condylax or Podophilox is the generic name. You'll treat somebody and think they're (the warts) all gone, then they'll come back months later. That'll happen with any kind of wart, whether it's a wart on someone's foot or in the genital area. It's frustrating.

"In terms of male cancer risk, particuarly in circumcized males ... it's extremely small. The risk in women -- it's been lowered significantly by frequent follow ups in terms of pap smears and treatment. If the pap smears become more abnormal, treatment can range from cryotherapy, which is freezing the surface of the cervix, to laser treatment of the surface of the cervix. Occasionally, if the changes seem to be invading the opening of the cervix, one has to perform a cone biopsy or what's called a LEEP, which is using an electrical loop to create a deeper biopsy of the area to remove the abnormal tissue.

Condoms, according to Lichtenstein, do not effectively protect one from contracting the papilloma virus. "It's very difficult, because unlike bacterial sexually transmitted diseases like ghonorrhea or chlamydia, where you're really well-covering the area where those bacteria would hang out, which is the opening or meatus of the penis, with condoms you're still going to get some exposed skin around the base of the condom. If the male has warts down in that area, they could certainly transmit them to their partner, and likewise, if a woman has warts, she can transmit them to the male in that uncovered area of skin."

While Lichtenstein advises sexually active students that condoms can protect against some sexually transmitted diseases, he also cautions them. "It's pointed out that they're not failsafe or foolproof. Most of the time when students are coming in because they're concerned about sexually transmitted diseases, they're already sexually active. Abstinence is discussed as an option, but frankly, I don't know how often someone who is sexually active becomes abstinent again." Likewise, Lichtenstein is reluctant to say what percentage of San Diego State students are sexually active: "The people I'm seeing here are a select population. I would guess that it's very high."

"It's kind of a silent epidemic. You don't hear much about it because it's not as dramatic of a sexually transmitted disease. It doesn't give you fairly noticeable symptoms like chlamydia or gonorrhea or herpes might give you where you've got some pain involved. It's something that's more easy to ignore. We recommend that women who are sexually active have periodic pap smears because they're good at picking up early changes that might be associated with the papilloma virus."

Theresa Pollock, 29, has worked at Planned Parenthood for six years -- as a health educator, then as as a community education coordinator. She was promoted to director of education and training two months ago. Pollock oversees programs for San Diego, Riverside and Indio: "My area in education is the prevention side ... We try to make it general -- it's not just STDs that we're focusing on, but just as with anything else on our body if there was a problem." Pollock says that the most frequent presentations are made in high schools.

Pollock agrees with Dr. Lichtenstein that skin to skin contact transmits the papilloma virus, the treatment is usually painful and not always effective: "They can burn it, freeze it, usually, they're removed from the skin, but, unfortunately, it can come back."

Pollock's (and Planned Parenthood's) answer for prevention initially sounds surprising: "When we talk about STDs, we talk about them in general and it applies to all of them. We obviously encourage abstinence as the only 100 percent way of prevention of any of the STDs and unwanted pregnancies. We absolutely encourage it ... but should they become sexually active, we want them to know what they should do to protect themselves. Number one, we always encourage them to really know their partner, take time to get tested, wait for results, and make sure that they're both clean of any STDs."

A glance at Planned Parenthood's teen website (www.teenwire.com) clarifies that by abstinence, Planned Parenthood does not necessarily mean avoiding sexual contact. For example, the website editors claim that abstinence has many meanings, including abstaining from vaginal intercourse, but engaging in other forms of sexual activity -- often called "outercourse". Pollock's view of abstinence is equally ambiguous: "We tell our youth to define it for themselves and then to talk to a partner as to what that meant."

But is it realistic to expect the average teenager to ask probing questions about a partner's sexual history and go with that partner for testing? "I believe that when we're in a classroom at least a couple of them are going to hear us and take the information to heart. It all depends on where a kid is at the time -- if it's relevant to them or not." Yet Pollock admits that "Probably less than half" of the teenagers Planned Parenthood speaks to will be tested for STDs.

While Dr. Lichtenstein asserts that condoms are not effective against papilloma, Pollock's agreement is conditional. She believes that condom use can be effective as long as none of the warts are left exposed. "Condoms are going to be better than nothing. Condoms are very effective when used correctly and consistently, but people do need to be responsible as to where their genital warts are located." But if the warts are often not visible, how can one be sure that a condom has covered the area enough to provide protection?

"I guess it would be tricky -- they'd have to actually know that they had them first of all. They would have had to have gotten tested, then once they're tested they do know --the doctor would tell them where they're located.

"If they do know that they have a disease like that, then they need to share that information, obviously, with partners." When asked if it's likely that teenagers will tell their partner that they have a sexually transmitted disease, she concedes, "Probably not."

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