Using humor to reduce stigma and stifle the surge in STIs

Ina Park, MD, MS, a professor at the University of California San Francisco and medical director for the California Prevention Training Center, believes that STI education and outreach doesn’t have to be alarming. In fact, she says, messages that are delivered with cheeky humor can have a greater impact.

Dr. Park, who’s also a medical consultant to the Division of STD Prevention of the Centers for Disease Control and Prevention (CDC) and co-authored the 2020 CDC STI Treatment Guidelines, believes storytelling and public engagement can fight stigma and fear around STIs. Her book, Strange Bedfellows: Adventures in the Science, History, and Surprising Secrets of STIs, skewers some misconceptions about STIs. But it may be her work with the CDC-funded HPV Impact Monitoring Project, which monitors the population-level effects of HPV vaccination, that’s getting the biggest buzz.

Her talk, “Butt of the Joke,” which she’s presented to researchers, clinicians, public health professionals, health educators and doctors in training around the U.S., starts with a personal anecdote. She recounts that as a peer educator at UC-Berkeley she donned a body condom, a safer sex promotion that launched a career. Emphasizing that STIs and HIV are no laughing matter, Dr. Park nevertheless encourages an injection of tasteful humor to spark engagement and make STI testing as routine and trauma-free as an oil change (assuming people get their oil changed without fear or loathing). I recently spoke with Dr. Park, who also sees patients at the San Francisco City Clinic, about humor as a way to reduce stigma and quell the surge in STIs.

‘Number one, I think it's the rise and now the ubiquitous nature of dating apps making it so easy for people to hook up if they want to’

Larry Buhl: Based on what you’ve seen in your clinic, why do you think there’s been a rise in STIs over the past few years?

Ina Park, MD, MS: There are multiple theories and I think that it’s not any one thing. But I’m going to tell you

four things that I think are contributing. Number one, I think is the rise and now the ubiquitous nature of dating apps making it so easy for people to hook up if they want to, which also mixes sexual networks in a way that didn’t happen before, when most people just like hooked up with people at their corner bar in their neighborhood, and you’re in your circle of friends. Now, I think it’s much easier to hook up outside of different networks.

Then, especially around syphilis, and especially around women, there’s the intersection of syphilis and the meth epidemic. Here in the West, about a third of the women with the most infectious stages of syphilis are also using meth. So there’s that piece of it. And I speculated that we were already on an increase, because people are a lot less afraid of HIV, now that we have PrEP and the whole concept of U=U around HIV treatments. So people living with HIV are undetectable, not passing it onto their partners. People who don’t have HIV are taking PrEP. And the final reason, I would love to think that, at least around chlamydia, maybe we’re doing a better job with screening people. And certainly, for the folks who are on PrEP, they’re coming in every three months and getting tested. So we’re finding more STIs that way.

Your presentation is about challenging the negative messages often heard around STIs. What are those messages and where do they come from?

I think STIs are often seen as a punishment by many people for sex you’re having outside of some heteronormative relationship. I diagnosed an older gentleman with HIV the other day, and he said ‘God is punishing me.’ I’m not talking about 30 years ago. This is happening right now. So I think somehow STIs are a reflection of some indication that you somehow did something wrong, or that you’re quote-unquote promiscuous.

I’m trying to tell a different narrative, which is that STIs are the cost of doing business as a sexually active person, and normalizing the fact that everybody’s probably going to get something at some point. But it’s a hard message to undo. Because we have a culture in the U.S. around purity, saving yourself for marriage. These are things that even I heard growing up.

'There is a generation of folks that not only got messages  about STIs as a punishment, but also that sex equals death.'

Where do you think most people are getting their messages about STIs? Is it from media? Or their family or their social circles? I’m trying to think of where I got my messages and can’t recall a source, at least not positive ones.

Did you get any messages from school, Larry?

Sex ed was basically a fifth grade class explaining how you reproduce.

In school, I got some messaging around STIs. But my messaging was all those horrible pictures of the worst case scenarios of people’s genitals. And if you have sex, if you have unprotected sex, which they’re assuming you’re going to have with a penis and a vagina involved, that this is what’s going to happen to you. So those are the messages that I got in my upbringing. I got nothing from my parents. And I think a lot of people make it all the way to adulthood, and even become sexually active, with no messages from their parents. I have a teenager who’s 16, and he’s getting a lot [of messages] from me, but they are getting a lot from each other, from their peers. And then they’re also getting a lot from social media, which is sometimes well done, and sometimes it’s just ridiculous.

I came of age at the height of the AIDS crisis in the 80s, where I thought if I ever have sex, I’m going to die a horrible death.

A lot of my gay friends and colleagues essentially were fatalistic about HIV. There is a generation of folks that not only got messages about STIs as a punishment, but also that sex equals death. But the generation of younger queer folks that I’m taking care of now, they don’t have that. I had it. I was so deathly afraid of catching HIV when I was becoming sexually active. And this generation doesn’t feel it and I’m happy about that.

But then they also say, ‘what’s the point of using condoms?’ So, we have to maintain more vigilance and more testing. Because what’s going to come with the territory is more STIs. I’m prescribing doxy-PEP [doxycycline prescribed after exposure] to prevent STIs, and that’s another reason that they don’t have to use barriers. But I don’t think that means we need to stop testing. We need to make it easier and less of a barrier.

There’s also stigma with sexual health clinics. And if a primary care physician is not sex-positive, you might worry about opening up about your whole sexual history.

A lot of patients that I’ve seen have had a terrible experience with somebody who judged them, or maybe didn’t call them a slut but essentially implied that they were. And so, they felt terrible and they’re never going to see that person. Or they can’t be honest about the choices that they think their physician is going to judge them for.

We doctors are so poorly equipped for this. In medical school, we get so little education about STIs in general, and forget how to make a sex-positive statement to somebody, and that’s something that you have to dedicate yourself to learning afterwards. It’s not standardized, and it’s generally not very many hours, and a lot of us come out very ill prepared. And then some of us are thrown into a situation where we’re taking sexual histories a lot, and then you get more comfortable. And then some folks do it so infrequently, that every time it’s very difficult for them. Most of the people that CDC funds us to teach are either working in public health, or people who are already practicing in some way, but I would love to do more medical student teaching.

‘If you can get somebody to laugh, and if you can use humor  without stigmatizing or making fun of any type of population,  then you hook people in.’

Which brings us to your presentation. What do you hope will be the result? Like a health department taking up some of the ideas here and making STIs less frightening at least?

I say kudos to San Francisco, because it is a quite a sex-positive place. And at least in the clinic, where I am seeing patients, we’re trying to make it welcoming and trying to make it less stigmatizing. But my hope [for this presentation is] I want people to shift their thinking and making [STIs] another component of sexual health and thinking about it more from an empowerment perspective. Like getting tested frequently is taking charge of your sexual health. It’s not about, ‘well, how many partners did you have?’ Or, if someone has more than one, then labeling them as ‘high risk.’ I really want to get away from that; that doesn’t help anybody. It just prevents people from wanting to come in to see you. I’m really all about lowering barriers to testing and making sticking a swab up your butt as inviting as possible.

When I’m tested and get asked about how many partners I have, I feel defensive.

Right. I think it just matters for someone to reflect on, ‘who am I playing with here and how much risk do I have?’ If somebody answers that they’ve had 20 partners in the past three months, then I would say they should be coming in every three months and getting checked, like having an oil change. Like you drive your car more, you need to come in more to get checked out. I look at it not as an absolute number, but it's a reflection of how to stay on top of your sexual health.

What are some of the ways that you think it’s important for someone in sexual health to use humor? And I guess it depends on whether the messaging is from the health department, or from a clinician doing intake.

I’ve seen some campaigns from health departments that use either humor or humorous images or fun images. It doesn’t always have to be funny, but making messages kind of fun and making graphics or making your marketing materials fun and upbeat, as opposed to showing somebody who looks depressed or sad, or all doom and gloom. There’s a lot you can do just with the messaging. Humor is disarming. If you can get somebody to laugh, and if you can use humor without stigmatizing or making fun of any type of population, then you hook people in. It’s a [better] way to get people’s attention to deliver a more serious message. And sometimes I do that when I’m doing my own teaching, because I do a lot of teaching of different doctors and nurses, and I’ve taught in colleges, I put myself at the center of the joke and I share my own history and experience with sex education in my own household. It’s safe, they can laugh at me and everyone’s in on it. You can’t make fun of other people unless they’re in on it with you and they’ve consented to be in on the joke.

Can you think of some STI awareness campaigns that used humor well?

In my talk there was one done in Canada around gonorrhea, which I thought was really cute, where they have a short video with a spelling bee and they have kids trying to spell gonorrhea. It was really funny because everyone is familiar with the spelling bee, and it was well done and the production value is pretty high. It almost seemed like a little Saturday Night Live skit. You don’t expect that kind of thing from the health department, which is why I think it’s so disarming. And I'm sure you’ve noticed that sometimes there are some funny billboards around Los Angeles as well. A few years ago, STD Check did a Pokémon campaign, ’cuz you don't want to catch ’em all.

Have you had any former students who come back and say they took some of your ideas about incorporating humor into learning into their practice or their outreach campaign?

I’ve had students and doctors reach out to me and say, ‘I liked that approach,’ or said that they felt inspired. And a couple of the doctors that I’ve taught are now working in sexual health, which is really gratifying. People can take my jokes, no problem. I’m happy if they steal my material.