A burning sensation. An itch that won’t go away. A rash. Yellow, brown or white discharge.
For many teenage girls and young women in South Africa, these are things you don’t talk about. They’re symptoms to hide — from friends, partners, parents and even healthcare providers.
That’s what research my colleagues and I at the South African Medical Research Council found when we talked to nearly 5 000 girls and young women aged 15 to 24 across the country about sexually transmitted infections (STIs) and vaginal infections.
South Africa has one of the highest rates of STIs in the world, with adolescent girls and young women more likely to have STIs than older women and boys and men of the same age.
Yet fewer than one in five of the girls we spoke to said they had ever been diagnosed with an STI such as chlamydia, gonorrhoea or syphilis by a health professional, even though many said they had at least one symptom of either an STI or vaginal infection, such as thrush (candidiasis) or bacterial vaginosis (BV) in the previous year.
BV happens when the normal balance of bacteria in the vagina gets disrupted. Normally, the vagina contains mostly “good” bacteria that keep the environment slightly acidic and protect against infection. With BV, other types of bacteria grow too much, upsetting the balance. Common signs include a thin, grey or white vaginal discharge, a strong fishy smell, especially after sex, or mild itching or burning.
Our study, which was published in the International Journal of Sexual Health earlier this year, found that shame, embarrassment and misunderstanding affect how young women understand and deal with STIs and other infections.
Although one 2022 study estimated that one in four women in South Africa have a curable, bacterial STI (which, unlike viral STIs such as HIV or human papillomavirus [HPV) can be treated), a quarter of the girls and young women we spoke to chose not to answer the question about STI symptoms.
That silence is as deafening as it is dangerous. The inability to talk about the infections can delay care, with missed opportunities to prevent bigger health problems later. Leaving STIs untreated can have serious long-term effects such as infertility, cancers, pregnancy complications and a higher chance of HIV infection.
What we found
In the survey, we asked participants about the following symptoms: itching, lumps, warts, rash, redness, unusual smell from yellow or brown or white discharge and pain or a burning feeling when urinating or having sex.
Genital itching — which can be a sign of BV, HPV or chlamydia — was the most commonly reported, with about two out of 10 saying they had experienced that in the past year.
Other commonly reported symptoms included unusual smell from yellow or brown or white discharge, which can be experienced when you have chlamydia, gonorrhoea or BV; pain or burning feeling when urinating or having sex, which happens when you have chlamydia, gonorrhoea or thrush; warts, rashes, bumps or lumps due to HPV or redness from thrush.
But most STIs are asymptomatic in women, which means that you can be infected without showing any signs. While vaginal infections such as thrush and BV are not classified as STIs, they can be transmitted through sexual contact but can also be caused by an imbalance of normal bacteria in the vagina due to using antibiotics, hormonal changes or wearing damp tight clothing.
In many South African communities, the vagina is wrapped in silence, indirect language and shame, with periods and vaginal fluids spoken about as dirty, shameful and disgusting rather than as normal bodily processes.
The stigma does more than police our language: it can change how women and girls seek care, talk about their bodies and even understand what “clean” and “healthy” mean.
Families help but silence remains
When we interviewed 68 of the participants in more detail, some young women said they trusted family members enough to disclose symptoms. While mothers, grannies and older sisters were important sources of advice, the conversations were often limited by embarrassment, moral judgement or a broader reluctance to talk openly about sex.
“I was talking with my granny about it and she was telling me that if I don’t use protection (condoms), I will get such diseases. She also told me that we’re not supposed to have sex before marriage.” — Free State, aged 15 to 17 (Note: not all STIs are prevented by condoms.)
Others said they would rather stay silent than risk being blamed or labelled. Conversations with friends also played a big role but the information passed around was often incomplete or wrong.
“[My friend] had an STI, it was obviously shocking, I mean we are friends … we share the same toilet. So … this could also infect me.” (North West, aged 18 to 24)
“(My friends speak about) a lot of bad things in terms of the vagina … they say there is no help.” (KwaZulu-Natal, 18 to 24)
Schools are teaching but not enough
School was the most common place where participants said they learnt about STIs, usually through life orientation classes, a compulsory subject which includes comprehensive sexuality education. That matters, because it shows schools are one of the few spaces where sexual health information is reaching young people widely.
But the knowledge was uneven. Some participants could clearly describe symptoms, transmission and treatment. Others confused STIs with other vaginal infections or held myths about how infections spread.
“You can even get it by using public toilets.” — Mpumalanga, aged 18 to 24
“STI are found in your vagina and you get them if you sleep around and do not take a bath and you can infect all the boys that you sleep with.” — Mpumalanga, aged 18 to 24
Many girls said that they only ever received information about HIV and never learnt about other STIs and genital infections. That points to a bigger problem: girls are getting snippets of information, not the kind of accurate, confidence-building education that helps them act early, seek care without shame and look after their long-term health.
Clinics are not enough
More than half of the girls and young women told us that if they thought they had an infection they would go to a clinic or hospital if they thought something was wrong. But girls aged under 18 were far less likely to go to a clinic than older girls, with only one in three under 18s saying they would seek care at a health facility.
“[If I thought I had an STI] I really don’t know where or what I will do.” — Western Cape, aged 15 to 17
Even though girls said they would try to get help, they said that they feared being judged, exposed or treated badly at clinics, which meant that some preferred pharmacies, private doctors or tried to find self-treatments on the internet instead of using public health services.
“The first thing I would do is go to the clinic if I feel something unusual down there … [but] I think they will shout at me because they always shout at people with STIs … [saying they] are irresponsible and reckless and they do not use protection.” — KwaZulu-Natal, aged 18 to 24
One of the main things stopping girls from seeking help for STIs is their fear of judgment by healthcare workers. They are scared that admitting they have an STI will lead to finger pointing, with healthcare providers scolding them for being sexually active at their age and assuming that they sleep around if they require STI treatment.
Why this matters
While HIV prevention receives consistent attention in the public health, funding and education agendas, STIs remain under-addressed despite the high rates and the fact that having an STI increases someone’s chances of getting HIV through sex.
As lenacapavir, the once-every-six-month jab that is almost foolproof in stopping HIV infection, rolls out in South Africa, it’s something healthcare providers are going to have to pay close attention to.
Evidence shows STI rates are concerningly high among those using HIV prevention medication; studies reveal more than a quarter of preventive medicine users test positive for an STI.
Some believe that you no longer need to use a condom if you’re taking preventive meds because you’ll be protected from HIV infection, but they’re not thinking about STIs.
Providing accurate and non-judgemental information is important but our study found knowledge alone is not enough. Young women need spaces where sexual health is discussed without shame, where symptoms are taken seriously and where care is easy to access without fear of being judged.
What we need is all-in-one, youth-friendly sexual and reproductive health services that combine STI testing and treatment with contraception, HIV prevention, counselling and psychosocial support.
Until then, girls and young women feel dirty and ashamed, too scared to ask for help for infections that could easily be treated.
Zoe Duby is a senior specialist scientist and socio-behavioural researcher at the health systems research unit of the South African Medical Research Council.
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
Shame, silence and incomplete sex ed are stopping South African girls from getting treated for sexually transmitted infections — even as rates remain stubbornly high
