To contract genital warts--a risk of losing love? Experiences of Swedish men living with genital warts.

Using a life-world hermeneutic approach, this study focused on the interviews with eight Swedish men living with genital warts. The men expressed a need for control over their situation, a control that was easier to maintain if the warts were invisible. Some of the men expressed prejudiced attitudes toward those who contract a venereal infection and their own feelings of shame appeared to correlate with these prejudices. In their meetings with health care providers, the men viewed a competent health care provider as someone who combined professional distance with a personal approach. Finally, the fact that men saw themselves as disease carriers was of great significance to them and influenced their views of future meaningful relationships.

Keywords: Swedish men, genital warts, human papillomavirus (HPV), life-world method, hermeneutics, existential experience, sexual health

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Several reports demonstrate that sexually transmitted infections (STI) are increasing in the Western world (Maw, 2004; Schofield, Minichiello, Mishra, Plummer, & Savage, 2000). Among STIs the human papillomavirus (HPV) is becoming more widespread among the sexually active population throughout the world (Baer, Allen, & Braun, 2000; Fleischer, Parrish, Glenn, & Feldman, 2001; Schneede, 2002). According to the Centers for Disease Control and Prevention (CDC), in 1996 there were over 24 million Americans infected with HPV (Fleischer et al.). Different epidemiological studies indicate the highest incidence of the infection is among young people between 18 and 28 years (Fernandez-Esquer, Ross, & Torres, 2000; Heley, 2003). In the first ten years of sexual activity, point prevalence rates approach 25% and the lifetime risk of acquisition may be as high as 80% (Heley, 2003).

Genital warts, also known as condylomata acuminate (other names include penile warts, venereal warts; Condyloma), are caused by the human papillomavirus: benign cellular outgrowths with HPV Types 6 and 11 causing 90% of genital warts cases. Genital warts are highly infectious and can be difficult to treat (Heley, 2003). If left untreated, they can spontaneously regress, persist, or grow (Zanotti & Belinson, 2002). Risk factors for HPV among males are multiple casual sex partners, smoking more than l0 cigarettes per day, not using a condom, and previous STI contagions (Diliner, Meijer, von Krogh, & Horenblas, 2000; Fernandez-Esquer et al., 2000; Wen, Estcourt, Simpsom, & Mindel, 1999).

Although these risk factors are well known, previous research shows that both sexually experienced and inexperienced young people fail to identify their risk for contracting a STI (Dell, Chen, Ahmad, & Stewart, 2000). According to Hammarlund and Nystrom (2004), young women with genital warts appear to disregard the fact that their own lifestyle could be a risk factor for contracting venereal infections. Condom use in Sweden has decreased by 50% over the last thirty years. In 1967, for instance, 38% reported they used a condom during their last intercourse; in 1996, the figure dropped to 15% (Voog & Lowhagen, 1992).

A STI can affect a woman's life at an existential level. It can create stigma and generate feelings such as shame, dirtiness, and disgust (Hammarlund & Nystrom, 2004). The physiological distress for a patient with genital warts is often much greater than the medical effect of the disease (Voog & Lowhagen, 1992).

There has been relatively little focus on men's experiences and feelings after contracting genital warts. Without such knowledge, it can be difficult to meet a male patient's needs, and to encourage responsibility in not spreading the virus. It also seems reasonable to assume that professional and caring encounters make it easier to consider one's sexual behavior and responsibility toward future sexual partners. To be able to create such encounters, it is necessary to explore the experiences of genital warts from the infected person's perspective.

The purpose of this study is therefore to analyze and describe the existential meaning of living with genital warts for a small group of Swedish men. This knowledge can assist in efforts to prospectively alter behavior and prevent disease transmission.

Method

Theoretical framework

This study used a life-world hermeneutic approach. Life-world-based research focuses on the "lived" experiences of the phenomena under study (Nystrom, 2006; Smith, 2007). In hermeneutic research, interpretation is key. The focus for this approach is thus to describe meaningful ways of understanding a phenomenon (Dahlberg, Drew, & Nystrom, 2001).

Hans-George Gadamer (1995), one of the most prominent theorists in the hermeneutic tradition, emphasized openness as a pre-condition for understanding something that is not already present in a person's pre-understanding. In this study, the first author (KH) tried to be aware of and suppress her pre-understanding from a previous study with a similar research question but one that focused on women with genital warts (Hammarlund & Nystrom, 2004). To do this, the authors discussed the possible effects of preconceived notions and ideas about the study's subject matter. According to Gadamer, researchers must be open to what is not immediately given, to see what he calls "the otherness" in data, i.e., something not previously understood (Dahlberg et al., 2001). In order to accomplish this, Paul Ricoeur's (1976) distancing, questioning, and critical approach to find overt and hidden meanings in the data was used; an approach that complemented Gadamer's notion of scientific openness. According to Ricoeur, it not only is important to understand, but we must also try to explain phenomena and their meanings in the process of interpretation.

Data Collection

The primary researcher (KH) interviewed eight Swedish heterosexual men, aged 19-31. Five had been diagnosed with genital warts in the past year, another had a relapse after being without warts for three years, one man had his genital warts on and off for three years, and one had suffered from chronic genital warts for nine years. The primary author consciously chose to interview men with different life experiences of genital warts. The youthful age range was chosen because HPV prevalence in men peaks between 16-35 years (Dillner, Meijer, Krogh, & Horenblas, 2000). The informants had all grown up in Sweden and came from a Swedish background. The reason for this choice was to exclude complications with cultural differences concerning attitudes toward sexuality.

Professional care providers working at a guidance centre and a clinic for sexually transmitted infections in two cities in Sweden provided 12 young men information about the study. To be included in the study, the following criteria were specified: a physician's diagnosis of genital warts, the infection had to be at least six months in duration, and, lastly, the man had to be willing to be interviewed and share his story. Of the 12 initially contacted, four did not want to participate because they felt the subject too private and intimate, while eight met the criteria and became the basis for the study. Three chose their home for the interview, one at the guidance center, and four in the principle researcher's office. The informants did not appear to know each other.

The life-world interview encourages the interviewees to reflect on their venereal infection and its consequences for their life situation. The initial question was, "Can you tell me about your genital warts and how it started?" This question was purposely open-ended to help the men to reflect on their lived experience with genital warts. Each one-on-one interview lasted approximately 45-60 minutes, was audiotaped, and transcribed verbatim.

Analysis

The transcribed interviews were read several times to gain a sense of the whole. Meaning units were then developed following the research question. This process allowed eighty-eight meaning units to become apparent. Next, these meaning units were compared to each other and then organized into sub themes by relating them. After this process, 31 sub themes remained. The sub themes were then organized according to similarities and themes were structured. Five main common themes and four-to-seven sub themes from each theme emerged from this process. We referred back to the interview text during the entire process of analysis.

In the next step, six interpretations were formulated to illuminate overt as well as partially covert meanings in the data. During this process, we returned to the themes and sub themes in order to ensure that all data of general importance were included in the six interpretations. Influences of the authors' pre-understandings were discussed. We further investigated whether the six interpretations could explain all the data in a reasonable way, and whether any data contradicted an interpretation that was assessed as valid. No interpretations were found that could better explain the data behind a valid interpretation.

Finally, all interpretations estimated as valid were compared with each other in order to find a consistent system of interpretations as well as a lowest common denominator, i.e., a main interpretation. The main interpretation is a comprehensive understanding that further explains all data of general importance for the research question. That question posed was "How do you experience living with genital warts?"

Ethical Considerations

Interviewees were given both written and verbal information on the study and confidentiality was assured. The human body can be experienced as very private and thus it is important the researcher acts in a way that preserves the participants' privacy. In this study, the interviewer (KH) was sensitive to this in trying to create an atmosphere of confidentiality and encouragement. Gothenburg University's ethics committee approved the study.

Results

First, the six interpretations, each which illuminates different aspects of the research question, are described. We then suggest a concluding interpretation that further explains the meaning in all the interpretations.

Having Genital Warts Creates an Urgent Need to Decide How to Handle One's Reaction

The interviewees' self-image seemed to be affected in different ways when they realize that they had contracted a venereal infection. For some, it appeared to improve their powers of attraction to the opposite sex since sexually transmitted infections sometimes seemed to serve as proof of sexual achievement. These participants did not blame anyone else for their genital warts; instead, they simply realized they could have lessened the risk of contamination by using a condom. This insight did not affect their self-image in a negative way.

Not all the interviewees conveyed such attitudes, however. For some, the infection was uncomfortable and embarrassing. The venereal infection was experienced as unfair because they did not consider themselves sexually promiscuous. "It is so terribly unfair, because people who know me know that I'm not the type to get VD. I no longer know whether there is a special type," commented one of the men.

These young men thus thought about their sexual behavior. Some considered themselves less judgmental than before and began to think about their prejudices regarding who contracts venereal infections:

   I have changed my attitude toward people who get VD. It was rather
   easy to get it, so I can't look down on anyone because of the
   infection anymore. Now these are normal people to me, no different
   from anyone else. It is just bad luck.

Hence, while those who experienced genital warts as a proof of their sexual capacity made jokes about it, others appeared to be more thoughtful and re-examined their lifestyle.

All the young men in the study thus seemed to sense urgency in handling their reactions, but in different ways. If the warts were visible, the situation was more difficult to control, as this example illustrates:

   The days I have visible symptoms are harder to get through. If they
   are visible you can point at something and say, "I have genital
   warts." Later when they are gone, you can't be sure. It feels
   better because you can't see them and point to the symptoms, then
   it feels less certain.

Most Reactions Depend on Previous Prejudices

For some of the interviewees genital warts were connected with feelings of shame and fear:

   When I was diagnosed with genital warts, I thought my life was
   over. I locked myself in. I didn't want to speak to anyone. I
   didn't go to school, instead I stayed in bed thinking, thinking,
   and thinking.... I didn't know anything about VD and I thought I'd
   die soon. Before I had been to the doctor and asked all my
   questions, I was so scared.

For others, especially those who spoke openly about venereal infections, the experience of contracting genital warts appeared not to be traumatic at all. Illustrating this perspective, one man reported, "I belonged to a world and a circle of friends where it was okay to have one-night stands.... I was just like the others I hung out with and could identify with them."

These men did not talk about shame and fear, but said the warts annoyed them. They were irritated because they had not used a condom and thus had to seek medical treatment:

   I had no other thoughts except that I had done something very
   stupid. I knew very well that I should have used a condom.... The
   whole thing was very irritating. I can't control it and that annoys
   me. You have a plan and like to have control of that plan, now you
   have to change that plan.

What is it that determines whether genital warts become a prescription for sexual success something you have to take into account when you change partners and do not use a condom, or a failure, a shock that arouses strong negative feelings? The differences in attitudes seem to be connected with previous attitudes toward venereal infections. Those who previously thought that only "other people" contract venereal infections have to reassess many of their own life values. One interviewee noted, "People who get VD are people who have a lot of sex--unprotected sex--and I didn't consider myself to fit in that category."

Genital Warts Bring Prejudices to the Surface

Some interviewees spoke openly about their earlier prejudices toward those who contracted venereal infections. Others seemed more or less to unconsciously put their own prejudices in other people's mouths. "I think," noted one man, "many people look down on those who have or have had VD, as bad people. You shouldn't say it, but you categorize them as sleazy." When this same man spoke about women with venereal infections, his judgment became even harsher. "It is easier to categorize girls than boys. I guess that has to do with some very old tradition.... It is hard to explain."

This man also tried to explain his attitude. According to him, prejudices are part of social attitudes, especially toward women:

   It must be something that goes far back. Like women always have
   been a minority in all big issues, like the right to vote, women
   have been housewives, all that kind of stuff. I think it comes from
   that and then it like stays put.

The fact that this man did contract a venereal infection became a gateway to further reflection. He went on to say, "Now I think that everyone is lumped together.... People with VD, I looked down on them at the start, but now they are like me."

Similar reflections occur in several interviews. Behind decisions not to tell anyone about the infection can be a concern about not being subject to other people's prejudices. As one man noted, "Now they stigmatize me as I once stigmatized them."

Presumably, this anxiety reflects the young men's own prejudices, at least before they were infected. One interviewee did not reveal anything about his warts to his friends since he feared their reactions and the disclosure of his secret in public. "If I was in a bar, for example, if I had told someone, I was afraid that a friend would say something. That he would tell someone else in a moment of thoughtlessness."

It is fair to assume that this is the same attitude as behind the choice not to talk to anyone except one or two very close male friends. Venereal infections remain something very personal because it is a negative side effect of sexual relations. Even if it is possible to speak about positive sexual experiences, it is not "glamorous" to have the misfortune to contract a venereal infection.

The fear of being exposed to other people's prejudices also gave the men cause for thought. Reflection formed part of the process of reassessing perspectives. Thus, they seemed to struggle with the prejudices they currently held, and it was important for them to revise their own prejudices before revealing their genital warts to others.

It is probably important to succeed with this conscious strategy, otherwise their own condemnation could reflect back on their own self-image. By working with their attitude in general, their feelings toward their own venereal infections might change. If successful, it might become possible to view other types of failure with humility:

   As stupid as it may sound, this has brought some positive things. I
   feel that I learned a lot, that I have grown mentally. You
   shouldn't take things so seriously; I have sorted out a lot of
   stuff in my mind. After a while, you gain distance to everything
   and that solves the problem.

It seems reasonable to assume that a revision of prejudices can have a positive outcome, generally, as some men experienced a sense of growth and increase in maturity when they were forced into a situation that made them feel less judgmental:

   In a strange way, you become more self-confident.... I feel more
   mature, more grown-up in a way.... I think I know more about who I
   really am, I am more self-confident in everything I do. I don't
   know if this is only related to the genital warts, but I think
   there is a pretty strong connection.

A Competent Health Care Provider Combines Professional Distance with a Personal Approach

The healthcare consultation was described as an important experience because of the venereal infection: it is more embarrassing when the consultation is for a sexually transmitted infection than, for example, for a broken arm. This becomes particularly important for those who did not know their diagnosis before the consultation. The meeting with the physician should be non-judgmental and time for questions is essential. The physician should also be prepared to answer sensitive questions. As one man noted, "The visit was informal and the information was factual. The doctor gave the impression that he liked his job and knew what he was doing."

The men also wished to attend a specialist clinic where physicians had many years of experience in diagnosing and treating young men with genital warts. "You get proper treatment," commented one man who went on to say, "There are no sour expressions; you can see that they are experienced. They know what to do when you meet them."

Since it can be embarrassing to show your genitals, the interviewees felt comfortable as anonymous patients in a clinical environment where the physician regarded genital warts as an everyday occurrence. At the same time, they wanted the consultation to be personal. This combination of wanting to be treated anonymously yet at the same time desiring a personalized consultation was viewed as the competent professional element in the consultation:

   He [the physician] joked about the clinic. We talked about the
   shame and laughed about dark alleys at night and things like that.
   It was very good. It was personal contact. Then he told me what
   kinds of treatments were available.

Consultations with physicians outside specialist clinics were not satisfactory:

   It was another doctor who prescribed the medicine the first time
   and who did not seem as professional. The knowledge that a doctor
   at a STD clinic and the staff work with this the whole time is a
   comforting thought.

Thus, for a consultation to be perceived as "professional," the physician helps the man to reduce the drama surrounding the fact that he has contracted a venereal infection. A physician who is accustomed to conducting such examinations and who approaches the situation with confidence, allowing time for questions, is successful in achieving this. The ability to switch between joking and making serious conversation in accordance with the patient's needs is a further sign of this competence. It seems much easier to regard the situation with optimism if treating genital warts appears to be an everyday occurrence. By reducing the drama of the issue, healthcare professionals can assist their patients in feeling less shame and negativity.

Feelings of Anxiety and Embarrassment Increase the Necessity for Caring Encounters

Reducing the drama of the situation as described in the interpretation above seems to be especially important for those men who are afraid and embarrassed:

   The doctor came in, we joked a little, and I immediately felt at
   ease, it was like a load off my mind. Earlier I was so scared, so
   scared. I guess he saw that I was terrified and could hardly talk,
   just tremble.... He talked about sexually transmitted infections
   with the same lightness as everything else we talked about and I
   felt okay; there are no limits here, it's cool.

In comparison, those who were irritated by the warts, but not embarrassed, appeared to have less need for comfort and trust in healthcare consultations. "I don't care which doctor examines me. I just want a diagnosis and treatment," noted one of the participants.

In contrast, those who felt a great deal of shame appeared to have kept their awkward questions to themselves for a considerable time and emphasized the importance of a consultation with a neutral, respectful, male physician regarding their warts:

   You feel so very lonely when you've got VD. It's not something you
   can discuss with just anyone. Once you get to the doctor, you want
   to talk about it as much as possible. You have thousands of
   questions.

These informants wanted to be part of an anonymous crowd afflicted by genital warts that the healthcare professionals meet every day:

   Just knowing that a guy like that doctor at the STD clinic and the
   staff work all day long with venereal infections that is
   comforting.... You feel embarrassed and even though they have
   professional confidentiality, you are still afraid that there will
   be a nurse or someone else you know.

There thus seems to be a connection between anxiety and embarrassment and a necessity for a caring encounter, even without the attitude that the patient is unique in contracting genital warts.

The Meaning of Love Makes the Men Vulnerable

When the young men did think about a future partner, in a genuine loving relationship, they had to realize the virus would remain in their body, making them carriers of the infection--a realization that hit them hard:

   From what I know, the genital warts will remain there, latent, it's
   not certain that they'll go away. That is really negative if I meet
   a girl I really want to be with. She will wonder what kind of guy I
   am. She might think that I've had a lot of sexual partners. I think
   that is negative. That's almost as embarrassing as having genital
   warts--that you've had a lot of sexual partners.

The interviewees were also concerned about their reputation. If it became common knowledge that they had contracted genital warts, their possibilities for love might be affected negatively. Here is how one of the men saw it. "Explaining about your warts is not a great pick-up factor. You want to protect your reputation."

They also contemplated about whether or not they should tell a partner about the virus:

   She might think that I've been unfaithful. That would be the worst
   thing, if she were a girl you really want to build a future with.

Moreover, they expressed their fear about infecting a girl they were seriously in love with. A consequence for at least some of them might be to avoid love, to make sure that they did not transmit the infection to a woman they love:

   It feels hard that the infection remains in your body when you go
   out and date girls.... You will stay away from some girls because
   of that. I mean girls that you can see yourself having a
   relationship with. You can infect her and it is easier to infect
   someone you are not serious about.

Why are not all sexual partners worth this concern? The answer might be found in the young men's fear of being rejected by someone to whom they become close.

Thoughts of having a venereal infection when searching for love seem to make all men vulnerable. When faced with the risk of disappointment in love, it does not help to know that genital warts are common or that your friends laugh at the situation. A love relationship involves a desire to be unique and special to the person with whom they are in love. Faced with losing the prospect of love made all interviewees vulnerable irrespective of their previous attitudes toward genital warts.

Concluding Interpretation: Seeing One's Self with the Other's Look

When a young man contracts genital warts, his whole self-image, consisting of the present, the future, and past, is affected. Attitudes from the past imprint his experience in the present. In addition, as a disease carrier, his future will be affected. A timeline links all three eras. When the young men in this study understood they were afflicted with a venereal infection that might be contagious for a long time, they seemed to change from subjects who judge others with venereal infections to objects of others' judgment.

In Being and Nothingness, Sartre (1943/2003) illustrates what happens when a person is transformed from a subject into an object. (1) According to Sartre, we experience another person (the Other) as an object of our judgments until we become exposed to the Other's look. Then we are transformed to objects of the Other's judgment. If we experience shame, for instance, we do so because we become exposed to the Other's look. In the Other's look, the men encounter notions about those who are afflicted with a venereal infection and why. In relation to the Other, they experience shame. They do not seem to reflect on the fact that what they see in other's look often has points in common with their own previous notions about venereal infections.

Those who previously had a reproachful attitude toward people who contracted venereal infections are consequently more ashamed than those who outwardly, toward their friends, seem proud of their active sexual life. The latter try in their fundamental attitude to flee from the shame and, before the Other, give an appearance of a certain pride, which Sartre describes as self-deception. In vain, the men try to impress the Other to, if possible, regain their lost freedom, the freedom lost by being in self-deception.

The men who feel ashamed seem more vulnerable in their contacts with professional care providers. For them it is important that a care provider combines professional distance with a personal approach and reduce the drama of the issue.

Those who in their self-deception regard venereal infections less "seriously" do become irritated about having to seek healthcare, but to them the single most important aspect is that the physician is competent in treating sexually transmitted infections medically. Thus, in order to understand the meaning of being afflicted with genital warts, the young men seem to search in the way they are seen by the Other. However, in doing so, they do not understand that they sometimes meet themselves and their own prejudices.

For each individual man, the existential meaning of being afflicted with a venereal infection therefore depends on what they think they see in the Others' look and, perhaps foremost, who the Other represents.

When the Other's look comes from a person who can provide love, the informant's vulnerability and exposedness increases. The man who sees fear of a venereal infection in the eyes of his loved one, fears being abandoned. The attempt through self-deception to regain subjectivity could fail when meeting a person who can provide love. The self-deception then becomes obvious when these men, standing before the possibility of a loving relationship, also become vulnerable.

Shame and pride may also vary depending on whom the Other represents. Reputation and status are at risk with friends, but self-respect and personal integrity are the focal points in contact with professional care providers. When facing the risk of losing love, the variation in the interview material ceases, which is probably because the deepest existential meaning of being afflicted with genital warts is found precisely here.

If the woman the man loves still looks upon him with love after being told about the contagious venereal infection, the shame as well as the threat to his self-esteem is overcome. However, if her look shows rejection, the man's fear of losing love is confirmed. Instead, the men could choose different strategies to prevent an encounter with the Other, an encounter that could lead to a love relation.

Thus, all the informants want to regain their lost freedom, regardless of what emotions the genital warts may have given rise to. However, for those informants that experienced shame and anxiety, the path is longer than for those claiming they have not. Not only do they have to seek a physician and go through treatment, they also have to deal with their attitude toward venereal infections on a more existential level. Under this process, which appears to be demanding they sometimes, isolate themselves from friends, school, and work. If they manage this adaptation, they gain a more mature and tolerant view of the world around them. On the other hand, those men who appear to be living in self-deception are not forced to face their notions until a possible love relationship contrives to challenge their project. It is then that they may be forced out of their self-deception and face a possible revaluation of prior conceptions about what, in the deepest existential sense, it means to have genital warts.

Discussion

Contracting a sexually transmitted infection means, at least for most of the men in this study, feelings of shame. Shame, however, does not necessarily mean something negative. The sense of shame is closely connected to conscience and tells us when something is right or wrong (Kjellqvist, 1993). Perhaps some feelings of shame are necessary to increase responsibility in not spreading the virus to others. If this is the case, it seems important for healthcare providers to discuss this matter with their patients. The healthcare provider also has to take into account that when patients with genital warts have prejudices about people who contract a STI, they want the healthcare providers to reduce the drama of the issue. These findings correspond well with Chandler (1996) who writes that the anxiety level of the patient will be reduced if the clinic has a warm, friendly, and relaxed atmosphere and if the attitudes from the staff are not judgmental, put the patient at ease, and is caring and helpful.

One of the main topics for the men in this research concerned the fear of rejection related to when to tell a new partner about the HPV. Our study shows that fear of rejection is stronger than any concern about not infecting a partner. This supports the findings of Taylor, Keller, and Egan (1997), who asked persons who had lived with HPV for one year what advice they would give to newly diagnosed individuals. Only 16% of the respondents advised newly diagnosed people to inform a partner, because of the fear of rejection once the partner becomes aware of the infection. Keller, von Sadovszky, Pankratz, and Hermsen (2000) interviewed 48 individuals with HPV and asked them if they had disclosed their HPV to their partner. Among those informants who still lived in the same relationship as before they were infected by HPV, 95% said yes. Among those men who had new a relationship, only 45% had disclosed their HPV infection to their partner. The reason for not telling a partner was a fear of being rejected.

According to Newton and McCabe (2005), the decision to disclose a STI or not has a profound impact on a relationship. It affects the degree of trust, intimacy, and communication in the relationship. It is important that the health care professional bare this in mind when meeting HPV patients. It can be challenging for the patient to disclosure to partners and therefore the healthcare professional need to bring up the subject for discussion.

Voog and Lowhagen (1992) conducted a study about men and the psychosexual aspects of living with genital warts. Their findings are similar to ours: most men worry about the risk of transmitting the disease to their partner and about uncertainty regarding when the disease is gone and not contagious. Voog and Lowhagen also found that only 17% of the men had used a condom for their most recent intercourse. Wulff and Lalos (2004) conducted research on condom use and found that the use of condoms was lower in some categories, which they define as subgroups. These subgroups were persons with many sexual partners, earlier experience of STIs, and in age groups above 25 years.

A major challenge for those working with sexual health and sex education is how to design effective education. This study shows that a possible question people ask themselves when diagnosed with a STI is how this could happen to me. How could I contract a venereal infection? Research conducted on young women with genital warts in Sweden (Hammarlund & Nystrom, 2004; Tyden, 1996) has revealed similar results. Hammarlund and Nystrom found that the women in the study were shocked about contracting genital warts and had strong prejudices about the kind of women who contracted a STI. They wanted to distance themselves from such girls because they saw themselves as respectable girls. This means that sex education and its goal to promote a healthy sexual lifestyle must help people understand that everyone who has sexual relationship with a new partner has the possibility of contracting a venereal infection. Succeeding in this education requires not only the provision of information that young people need, but also that teachers and healthcare professionals working in this field talk to young people about attitudes and behavior toward sexuality.

The sexual behavior of young people will follow them into the future if they contract a sexually transmitted viral infection. Informing young people that they need to use a condom in new sexual relationships is not sufficient if the goal is to change a person's sexual behavior. It is necessary to go into depth on this subject and it is important that young people can discuss their sexual habits and the consequences of changing sexual partners many times. Hence, this appears to be a challenge for professional healthcare providers. It is essential that the issue is not handled in a moralizing way, it should rather help young people become more aware of what risk they expose themselves to when changing sexual partners. Teachers, health care providers, and other professionals that work with young people must dare to discuss sensitive matters in greater depth when society is becoming more overtly sexualized. Many teachers and healthcare providers seem to be very focused on medical information. We recommend that sex education consist of more profound issues such as love, respect, and responsibility. What a young person does today may influence his or her life tomorrow. The increase in sexually transmitted infections in the Western world is problematic for society as the whole as we face the consequences of STI as bacterial infections can cause women to become infertile or to develop cervical cancer due to malignant HPV.

The authors gratefully acknowledge the financial support of the Skaraborg Institute for Research and Development.

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(1) According to Sartre, we experience others as objects until we are exposed to the Other's look. The freedom of being master of the situation is taken away from the person who becomes the focus of the Other's look. The "look" turns the recipient into an object, which gives the Other an opportunity to judge, with no possibility for the exposed individual to influence the judgement of him or herself. The shame of having lost the freedom to another subject is the fundamental idea of being exposed to the Other's look.

Kina Hammarlund, Department for Health and Natural Science, University of Skovde and University of Vaxjo, Sweden; Ingela Lundgren, Department of Health and Natural Science, Boras University College and University of Vaxjo, Sweden; Maria Nystrom, Department of Health and Natural Science, Boras University College and University of Vaxjo, Sweden.

Correspondence concerning this article should be addressed to Kina Hammarlund, Stockvagen 115, S-541 62 Skovde, Sweden. Electronic mail: [e-mail]