Should We Show Pictures of STIs in RSE?

RSE practitioners might be tempted to show graphic pictures of STIs. Here I’ll argue why this is a bad and counterproductive teaching method in relationships and sex education.

They Don’t Work

You might think that the widespread use of showing these kinds of images might be based on some kind of evidence of their effectiveness, but you’d be mistaken. Dr Alyssa Lederer, applied behavioural scientist and health education specialist, found the following:

“In 2016 I conducted an experiment with young people enrolled in a large public Midwestern university. Participants watched one of two randomly assigned web-based sexual health programs, one with graphic sexually transmitted infection images and the other without such images but otherwise identical. I then compared the two groups of participants to assess their knowledge, beliefs, and behavioral intentions related to sexually transmitted infections. Overall outcomes were the same, but when I asked participants to provide feedback, more than a quarter of those that saw the graphic images expressed disgust and dismay. These results suggest that presenting such images may prompt stigma – without having any health benefit.” This point about stigma is very important, which I’ll come on to next.

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Meanwhile other studies studies looking at the effect that scare tactics, also known as ‘fear appeals’, have on people around STIs show a similar lack of evidence of effectiveness. Allison Earl and Dolores Albarracín’s study looked into the use of fear appeals (explicitly talking about the dangers of HIV transmission during a consultation) as part of HIV testing. They found that fear appeals during these consultations: “increased perceptions of risk at the immediate follow-up but decreased knowledge and condom use.” This study also found that this decreased condom use following a fear appeal actually strengthened over time (a spiraling effect). Importantly, when interventions instead offered HIV counselling and testing there was an increase of knowledge, and an increase in condom use and this effect strengthened over time.

There has been a long history of study of fear appeals or scare tactics and the evidence is contradictory. Some may work in some interventions where individuals are scared enough to want to change their behaviour and that change is feasible and accessible to them. However, using a condom is not always easy and it’s certainly not as easy for some people to negotiate using condoms as others. When it comes to condoms, Earl and Albarracin’s study (and also other studies) suggests that messaging which promotes the gains of condom use, rather than highlighting the losses of condom non-use, are more successful in both the short term and also in the long term.

So studies in the classroom and studies from clinics suggest that scare tactics don’t work work and may even be counterproductive for safer sex practices. Why else might it be a bad idea?

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They Create Stigma

As Dr Alysssa Lederer found that showing images of diseased genitals did not increase the knowledge of students taking part in that RSE programme, but that it did increase levels of stigma. Study after study shows that stigma has a huge role to play in delaying young people’s attendance at a sexual health clinic, even when they think that they may have symptoms of an STI.

“To promote prompt treatment-seeking, interventions must also address both STI-specific and other forms of social stigma which may limit access to care.” Malta, et al 2007

“Strenuous efforts should be made to overcome the stigma associated with STIs and, by default, GUM services, and to present sexual health services in a way that is seen as inclusive and relevant to a wide range of individuals.” Anne Scoular, et al 2001

“High perceived seriousness about symptoms has both cognitive and emotional components that may function independently to either promote or delay STD-related care seeking.” Cunningham, et all 2005

Sexual health education, which seeks to ‘disgust and dismay’ is going to create more stigma around STIs and thus around accessing treatment. (Although there have been significant increases in young people accessing sexual health services due to the expansion of young people’s sexual health services in the noughties). Delaying treatment, or avoiding treatment, increases the risk of transmission and increases the risk of long-term health effects.

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In addition showing these images risks perpetuating other harmful stigmas around sex, which invariably intersect with oppression. Together this sends a message that there are certain ‘kinds of people’ who are at risk of STIs. These messages are homo/biphobic, racist, classist, and definitely sexist. It also creates this problematic and sex negative ‘other’ who has, and might even enjoy, sex. RSE should be trying to address these kinds of messages, not perpetuate them.

So showing these images of disease sends out messages about sexuality and stigma which are very harmful and counterproductive but are also inaccurate.

They are Inaccurate

The majority of cases of STIs don’t have any symptoms. Even where there are symptoms they might be very mild and so not recognisable, or they may be confused with other infections or conditions (such as a heavy cold).

The graphic images of STIs which are used in sex education show individuals with symptoms. So in order to be accurate people showing these images should also be showing pictures of people with STIs but no symptoms. We don’t do that because 1) people with asymptomatic STIs are not deemed worthy of photographing by medical professionals and 2) a lot of people will find it inappropriate to be showing young people pictures of genitals without symptoms ie, just genitals.

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Furthermore, the symptomatic pictures of genitals are atypical: that is to say, they show large clusters of warts, or voluminous discharge, or symptoms of tertiary syphilis. These are rare. So they don’t even show the kinds of images of symptoms that people may want to look for when they are checking out their bits in the shower or bath – a small wart, or a blister, drops of blood, a small rash, or an unusual discharge.

Sidenote: I think that we should probably be doing more to teach young people about their genitals. In addition to teaching about diversity (and similarities) of genitals we should also be teaching more about vaginal discharge, papules, in-grown hairs – which are often mistaken for STIs.

So they are not typical images of STI symptoms and thus are not accurate images of STIs. They also have the effect of making STIs seem more serious than they are. The fact is that all STIs are treatable (although yes, gonorrhoea is getting more difficult to treat but is still pretty uncommon), and once treated it’s not common for STIs to have a long term effect for young people. Even rates of HPV, which is the most common STI in the UK, are coming down dramatically thanks to the HPV vaccine for young people. Rates of genital warts (which are low risk STIs not associated with cervical cancer or any other long term effects, but still feature heavily in graphic images of STIs) have reduced by nearly 80% in young people. We’ve seen that scare tactics don’t work, but we also saw that an overemphasis of how serious STIs are will also increase stigma.

So How Should We Teach About STIs?

Even though we should still teach about STIs, we probably need to tone down some of the messaging in order to a) remove the scare tactics and b) usualise STIs just like we might with any other illness. We should also shift the emphasis to talking about how to negotiate safer sex (and giving people the tools to do this) and how to access sexual health services.

Below are some images I made for @BishSexEd on Instagram and Twitter, feel free to download these STI slides and use them in your classes.

 

You could also try my STI quiz over at BISH which I describe as “a fiendishly difficult quiz but also pretty chilled out and quite real life.”

You could also try playing my game Safer Sex Aces or using my Condom Teaching Pack

You could also try the Safer Sex lesson plan over at DO… RSE for Schools,  which I wrote with Alice Hoyle.

There are some more really great ideas about how to teach about STIs in this lovely article by Chella Quint.

If you’re a teacher in the UK, why not join our facebook group? which Alice and I moderate. It’s a lovely community of teachers who would want to improve their practice.

© Justin Hancock, 2019