call for papers

reproductive and sexual morbidity: neglected problems

volume 20   number 40   november 2012

Much of the time in public health and human rights work, we are trying to reduce mortality by preventing and treating potentially fatal conditions before they get so bad that it is too late to save a person’s life. We concentrate on mortality because there are so many untimely deaths.

What sorts of morbidity problems are there in relation to sexual and reproductive health? Here is a partial list, taken from some of the papers RHM has published on this subject to date:

In women

Reproductive tract infections
Sexually transmitted infections
Sequelae of unsafe abortion
Benign breast disease
Disorders of menopause and peri-menopause
Uterine fibroids
Urinary tract infections, leaking/incontinence
Infertility
Contraceptive side effects
Excessive, frequent and irregular menstruation
Absent, rare and infrequent menstruation
Painful menstruation
Endometriosis
Pelvic inflammatory disease
Breast lumps
Osteoporosis
Genital/uterine prolapse
Reproductive cancers and their precursors (breast, cervix, uterus, ovaries, genitals, anal)
Painful sexual intercourse/lower abdominal pain/lower back pain
Abnormal vaginal discharges
Obstetric morbidity starting during and after pregnancy
Post-partum and other SRH-related depression

In men

Reproductive tract infections
Sexually transmitted infections
Urinary tract infections, leaking/incontinence
Infertility
Osteoporosis
Reproductive cancers and their precursors (anal, penile,
testicular, genital, prostate)
Abnormal penile discharges
Equivalent of menopause in men
SRH-related depression

This is a formidable list, and the burden of disease from these conditions is large. Some problems start in adolescence. Many others arise during people’s sexually active and childbearing years, and still others in middle and older age. Unless we focus on reproductive and sex-related morbidity, on conditions that may go on for years, quality of life for the people experiencing them will be reduced or even destroyed.

Take sexually transmitted infections, for example, one of the most common, most studied forms of morbidity, and among the least treated. More than 448 million new cases of four bacterial STIs – gonorrhoea, chlamydia, syphilis and trichomoniasis – are estimated to have occurred in 2005 (1), and this is an annual occurrence. Much of it goes untreated. Is this a tolerable state of affairs?

I was just at an excellent conference on “multipurpose prevention technologies” and there was a presentation on which forms of disease burden to concentrate research & development of new medicinal products on – HIV/AIDS, STIs and or unwanted pregnancy. STIs were seen as having lesser priority. Why? Because they don’t kill so many people. And women were seen as needing “more protection” than men. I challenged both of these assumptions.

Qualitative research in this area would be incredibly valuable. Michael Koenig showed the field how incredibly complicated it is to do clinical research on the type and extent of morbidity – his two papers in RHM based around his work in India, and many others that he was involved in, are still essential reading. No one should think they can go out and do a study with clinical significance that is quick and easy. But study this we must.

RHM has published four important papers on reproductive morbidity in Egyptian women [RHM 2(4) November 1994], Brazilian women [RHM 6(11) May 1998], and two about Indian women [RHM 9(18) November 2001]. Their methodologies were first class, but the data are out of date. We have published a few others on specific problems, such as perceptions of RTIs, experience of uterine prolapse, and sequelae of female genital mutilation. But there is so much more to know and a huge need to figure out how to address many of these problems, both chronic and acute.

And if these problems are neglected in women, then what about in men? Is my list even accurate, let alone complete? What’s a better way to talk about morbidity related to sex? I wait to be corrected!

This journal issue will be exploratory. Commentaries, case histories, qualitative reports, self-medication, perspectives on how dealing with these forms of morbidity can possibly be taken up in struggling health care systems in middle- and low-income countries, whether or not developed country health systems are doing as well as they should, whether morbidity is falling at the same time as mortality, e.g. from unsafe abortions; whether prevention and/or treatment are succeeding in reducing disease, e.g. with genital warts following HPV vaccination; evidence that some diseases such as gonorrhoea are becoming untreatable due to antibiotic resistance; and whether help for menstrual problems is any better now than it was in previous decades – these are only a few suggestions for papers.

(1) World Health Organization. Prevalence and incidence of selected sexually transmitted infections: Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis and Trichomonas vaginalis. Geneva: WHO, 2011.