Can the stigma of sexually transmitted infections affect the reported route of transmission by patients from particular sociocultural groups?

Sir: We read with interest the article by F Khorvash et al. ¹ and would like to thank their contribution in reporting this interesting case from a country where medical literature on the incidence of sexually transmitted infections (STIs) is rather scattered. Although indirect transmission of STIs through either zoophilic intercourse ^1,2 or non-sexual contact with fomites ^3–5 has been reported, this mode of transmission is extremely rare and remains controversial.

In countries where any extramarital sexual contact (hetero- or homosexual) may be considered as an illegal, non-culturally acceptable or antisocial behaviour, patients more frequently report unusual modes of transmission as a protective conservation. In these countries, patients do not usually and honestly reveal either the nature of their sexual activities or the source of intercourse due to sociolegal reasons or for fear of persecution. Unusual explanations that individuals with laboratory confirmed STIs, who consistently deny any sexual contact(s), typically make to describe the route of transmission may vary from one person to other and have a wide spectrum, and can in turn depend on factors such as patient's sociocultural status, religious beliefs and sexual education. In some instances, the relative stigma of ‘admitting’ zoophilic intercourse would be more preferable to admitting extramarital relations or homosexual activities, both of which may be considered as criminal activities.

Our observation in a period of four years (2001–2005) from two private medical institutions in Tehran, Iran shows that patients may provide such unusual excuses to explain the mode of transmission of confirmed STIs when any sexual activity is denied: allergic reaction to a particular drug, food or drink; contact with shared moist objects such as towels, wet clothing or soap bars; skin contact with known/unknown chemical substances (e.g. washing powder/liquid, detergents, pesticides, etc.); going to public toilets, swimming pools, spas or saunas; heavy cigarette smoking; insect bite(s); masturbation with contaminated hands; psychological stress (e.g. school exam, shock, etc.); sharing of friends' or family member's underwear/swimsuit; trauma to genitalia (e.g. prolonged driving, excessive physical activities/exercise); travel/holiday to other parts of the country; or urinary tract infection (in the absence of a true infection). These and other such reasons, including zoophilic activity (often in rural areas), may seem to be believable excuses to those who do not have a reasonable knowledge of the true routes of transmission of such infections.

Providing false personal information is another common practice among individuals attending the private medical sector for screening, diagnosis and treatment of STIs. Furthermore, many victims of sexual assault neither report the event to police agencies nor obtain medical care. To our knowledge, in the country where the case was reported, there is usually no structure to reassure STI-infected or suspected individuals that their clinical records will be considered confidential and not be translated to non-health-related organizations.

Where and when extramarital sexual activity, particularly homosexuality, may be considered as an offence, false-reported zoophilic intercourse by the patient should be considered to be more probable than a genuine and actual animal sexual contact (although not impossible), to cover the natural route of human-to-human transmission and protect the patient and his/her partner(s).