19
Warts and Herpes:
A Tale Of Two Sexually Transmitted Diseases

We are in the midst of a worldwide epidemic of sexually transmitted diseases. At least two of its major diseases are helped by psychological techniques: twenty-six to thirty-one million Americans have genital herpes; forty to fifty million Americans have venereal warts.

We must carefully distinguish between having either the virus and having the symptoms. The both creepy and reassuring reality is that we all swim in a sea of viruses not only outside us but within us. If you have ever had chicken pox, mononucleosis, or other such diseases, the virus is now in your body. Usually its presence has no impact. Although recent figures are lower, at one time as many as 90 percent of Americans had the herpes virus for cold sores in their bodies. Perhaps two-thirds of the people who have the possibility of genital herpes have had one or several outbreaks but do not have subsequent symptoms.

Warts are caused by forty or fifty variants of the human papilloma virus (HPV). While its story is not as clear as herpes, a vast percentage of the world population has had a wart at some time. A British study found that 16.2 percent of schoolchildren had active warts (it is not clear how many had the virus in their bodies but not active). As many as 30 percent of American women may have the virus for venereal warts within their bodies.

Here enters the immune system. Its job is to maintain law and order. When it is functioning well, all of these microscopic predators are kept in their place. It puts an end to herpes recurrences and often produces the spontaneous remission of warts. The emerging field of psychoneuroimmunology studies the impact of psychological factors on the immune system's ability to function effectively.

Preventing transmission and knowing what to say to sexual partners require both specific information and personal judgment. The guidelines are being updated as new research comes in, so consult your health care provider. The key to avoiding transmission is having the partner avoid contact with affected skin when the virus is present. Condoms are effective if they cover the affected area, and nonoxynol-9 spermicides also kill the virus.

A common rule for genital herpes was to avoid intercourse or other contact with the affected skin from the start of the prodrome (tingling, muscle aches, or other indications of a coming recurrence) until two days after the healing of sores. This has been complicated by a growing awareness of the role of asymptomatic transmission?that is, transmission with no visible sores. It is not clear how common this is. One study concluded that it is quite rare yet another called it the major source of transmission. The danger of asymptomatic transmission appears to diminish sharply after the first six months. The clear message is that there is no clear message.

Venereal warts present similar ambiguities. Warts seem to differ in their incubation periods (how long after exposure you see them) and the presence of virus after apparent clearing. One rule of thumb is to consider the virus as possibly transmissible for six months after possible exposure and for the same time period after visible symptoms have gone away.

Let's first cover some of the common non solutions to these ambiguities:

'Official or unofficial self-imposed celibacy:  Avoid all encounters, flee when sex is on the horizon, or just don't ever find anyone who turns you on.

'Limit yourself to a series of casual sexual partners, telling yourself that they don't need to know.

'Only get involved with people whom you don't care about being rejected by.

'Find someone who is comfortable with the problem and stay with him or her, even if you know the relationship is going nowhere.

Whom do you tell, what, when, and how? What information do you owe to a new lover? Does using a condom change things? What if your herpes or warts are not on the scene this week, this month, this year, this decade? These intensely personal questions cannot be answered by formula or appeal to authority. Only you can make the decision.

What I do offer as a guideline is one of the oldest approaches to moral dilemmas: "Do unto others as you would have them do unto you" Imagine that your positions were reversed; that your sexual partner was the one weighing what to say and do. Consider each of the options with them in your shoes and then act accordingly.

The Herpes Resource Center newsletter, The helper (Summer 1987), suggests ways to make telling a partner easier:

'Try and develop a positive, self-accepting attitude toward the problem. (You can't ask someone to accept something you haven't accepted yourself.)

'See the affirmative side of sharing this information. Remember, you are clearly exhibiting trust in a new (or prospective) partner. That is the first step toward intimacy.

'Be well-informed. The ability to answer your partner's questions thoroughly goes a long way toward building mutual confidence.

'Use outside information sources. They can reinforce information and offset fear and anxiety.

'Try to avoid predicting or presuming a partner's reaction. To assume that he or she will necessarily be upset can be a self-fulfilling prophecy.

Another good rule of thumb is to pick a low-key, neutral, nonsexual time and place to raise the issue.

Both herpes and warts introduce extra complications in pregnancy. Neither of the most useful drugs, acyclovir for herpes or podophyllum for warts, are approved for pregnant women. Extra precautions are important to protect the baby from the virus. The suspected link between herpes and cervical cancer has not been supported. The links between genital and anal cancers and warts appear to be more substantial.

All forms of warts and herpes raise the question of transmission from one part of your body to another (autoinoculation). This is fairly hard to do, so while it is important to exercise good hygiene, don't drive yourself crazy about it. Ocular herpes does exist and is the most common infectious cause of blindness, but it is rare and virtually never is transmitted from oral or genital recurrences. Precautions: don't touch your eyes after touching active sores; don't put contact lenses in your mouth if you have a cold sore, are worth observing anyway.

Increasing evidence suggests that any condition that produces breaks in the skin of the genitals can increase vulnerability to any other sexually transmitted diseases, including AIDS. Because herpes is a fast-spreading disease involving the genitals and is recurrent, its psychological impact can be devastating. In a survey conducted by the Herpes Resource Center,84 percent of people with herpes reported depression, and 42 percent deep depression; 25 percent said they had self-destructive feelings; 35 percent reported diminished sexual drive and 10 percent withdrew totally from sexual involvements; and 70 percent reported a sense of isolation. Work performance suffered for 40 percent.

Such turmoil may markedly turn the course of the disease for the worse. Depression and other emotional upsets may impair the immune system that otherwise keeps the virus in check.

Anxiety about recurrences may trigger what is feared? a phenomenon I call "avalanching." When a Time cover story about herpes appeared, it aroused shame, anger, and anxiety in people with the disease? and a number of my patients suffered recurrences as a result.

Knowing that emotional turmoil triggers recurrences, people will unjustly torment themselves for feeling tormented. Similarly, people need to identify and reverse agglomeration, blaming the disease for everything wrong with their lives, including sexual problems, depression, and social withdrawal, that they may have needed help with even before they got herpes.

Not everyone with herpes reacts the same way, of course:  like any disease, it affects you most strongly where you're most vulnerable? your emotional Achilles heel. The disease gets tangled up with unresolved issues that have lain beneath the surface since childhood, creating a double dose of turmoil.

It is vital to ask yourself what the symptom is doing for you as well as to you. I can cite many instances where recurrences played the role of sexual policeman, inflicted self-punishment, or resolved conflicts. A twenty-eight-year-old artist wanted to become a father, for example, but suffered a recurrence whenever his wife was fertile: clearly, the virus was acting on behalf of his doubts about parenthood. A twenty-six-year-old computer executive who harbored deep fears of intimacy endured recurrences whenever he met a woman who threatened to engage his affections by exciting him both sexually and emotionally. A religious forty-two-year-old advertising executive found herself drifting into an affair with a married man; she felt torn between passion and principle, until her herpes resolved her dilemma.

Venereal warts also often play the role of sexual policeman. They orchestrated one patient's ambivalence between his wife and girlfriend: whenever he was ready to return home, warts on his penis flared up and made his wife reluctant to take him back. With the hypnotic suggestion that he handle the situation directly, the warts vanished within three weeks. A twenty-seven-year-old insurance adjuster suffered from anal warts and a fear of anal intercourse. Once he accepted the fact that he was in control--no one would subject him to anal rape so the warts were unnecessary--they vanished in two sessions.

Our understanding of psychological treatment of genital herpes and venereal warts has been helped by research on the nonsexually transmitted versions going back to the 1920s. The viruses' responsiveness had been staked out well before the sexually transmitted versions ever reached epidemic proportion.

Biological factors help determine why some people never have herpes recurrences or warts while others have them ceaselessly. Different variants of the virus seem to be more prone to create symptoms and to be better adapted to thriving in one or another body part. For many people, emotional factors are critical in determining the frequency and severity of recurrences.

In 1928, two Viennese physicians didn't stop with using hypnosis to alleviate oral herpes symptoms. They also demonstrated that hypnotic suggestions could experimentally trigger recurrences.

More reports appeared sporadically for the next fifty years. Then in 1981 at the University of Bologna, Arone Di Bertolino used hypnosis for nine patients who suffered genital herpes recurrences weekly or bimonthly. One and a half months after treatment, six had no recurrences, three only one or two.

Early successful treatments of nonvenereal warts also date back to Europe in the late twenties. The best controlled experimental demonstration of hypnotic treatment of nonvenereal warts was done here in Boston in 1973.8 After five weekly hypnotic sessions, 53 percent of patients were wart-free. The untreated control group was unchanged.

A later study tried to pin down the "active ingredients" and predictive factors in hypnotic wart treatment. As well as confirming the effectiveness of hypnotic and self-hypnotic treatment, the study found that the ability to form specific images vividly was more important than general measures of hypnotic ability. Interestingly, people with more warts got better results. I have found common warts to be the most responsive of all the problems that people bring. They often arise at times of developmental challenges, transitions, or blocks. Quite often people become able not only to make their warts disappear but simultaneously to get their lives back into gear.

Nonsexual warts are probably the best researched and accepted application of the techniques in all of dermatology, so it is puzzling that almost nothing is being done to apply this to people with venereal warts. The two clinical reports that have been published are very promising. I have had good results with the few people who have come in, but there is some block in the minds of both physicians and patients.

Most people are looking for their warts or herpes to go away first, but real gains can be made on other levels, too. I think of genital herpes as three diseases: medical herpes, an infection caused by a virus; psychological herpes, the emotional impact of the disease; and media herpes, the burden of being a central player in a modern morality play, complete with the wages of sin, lepers and whores, and scarlet letters.

A graphic demonstration of the pain of media and psychological herpes versus medical herpes was provided by a woman in my group who had been infected some years earlier. She had always dismissed the misdiagnosed outbreaks as a nondescript, vague annoyance, but from the moment her herpes was correctly diagnosed, she was plunged into turmoil and anguish.

Most people with venereal warts have to grapple mainly with the medical and psychological versions, but especially in the era of AIDS, any sexually transmitted condition can come with the extra baggage of fear and shame.

At the writing of this second edition, some of the herpes hysteria has settled down, but it is not entirely clear that this has translated into a lessened impact on individuals. I frequently hear, "I know I shouldn't be feeling so upset about my herpes; after all, it's not a big deal medically and it isn't AIDS." So now they suffer a double dose: they're not only upset about the herpes but also because they "shouldn't" be so upset.

Support and mutual help groups have become an established approach for helping people with genital herpes The Herpes Resource Center actively supports research with direct support and congressional lobbying, it maintains a hot line, it publishes The helper, an excellent newsletter, and it supports local help groups and educational conferences.

There are now similar support groups for those afflicted with venereal warts.


Legal Issues 

The legal implications of sexually transmitted diseases are developing rapidly. In some states, it is a criminal offense to transmit a sexually transmitted disease (STD). A growing number of people have successfully sued the person who infected them without informing them of the possible risk. This is a very complicated matter legally, psychologically, and sociologically. I served as an expert witness in a case that was successfully settled out of court. While each instance needs to be examined individually, I came away convinced that there are instances in which legal action, although quite demanding emotionally, is ultimately therapeutic.

Two of your reasons for hesitation may be smaller obstacles than you imagine:  the case can be "sealed," with proceedings behind closed doors, and your name not be used. You may imagine that your mental state either before or after transmission, could be used to make you look bad. Quite the contrary, your present turmoil may well be part of the damages for which you should be compensated. If you were in rough shape before transmission that also may help your case. The legal doctrine of the "eggshell plaintiff" states clearly that damages resulting from preexisting vulnerability deserve compensation. You were who you were at the time and that is no excuse.

No news is all good or all bad. We've looked at possible advantages of sexually transmitted skin problems like the "sexual policeman." These are ironic advantages:  they give us things we may feel we need but are better off without. There are also other more straightforward advantages. Certainly few would argue that they are actually worth the aggravation of having the problem; think of them more as a compensation or partial payback. Here are some in the words of the people who discovered them:


'"I'd probably still be doing the bar scene if my STD hadn't brought me up short and forced me to look at what I was running from."

'"When we couldn't have intercourse, my husband and I discovered a whole wealth of sexual activities and subtleties that we'd lost."

'"I am now a better human being, more open, compassionate, caring, and honest. Looking back, I used to be a real shit."

'"I'm much more in touch with my body's needs than I ever was before I got it. 'Stress control'' used to be just a Yuppie cliché. No more."

'"It forced me to learn to talk honestly about sex, and that ability has carried over to other areas."

'"Getting herpes heightened my self-hatred to the point that I had to get into psychotherapy. It changed my life."

Tuning in to the upside (without whitewashing the downside) may increase your body's ability to handle viruses. Silver linked active coping (versus resignation or wishful thinking) to improved outcome for people with ten or more herpes recurrences a year. Kemeny and associates linked depression, fewer suppressor T cells, and more frequent herpes recurrences.

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