Mark Borigini M.D.

Overcoming Pain

Of Spring, Sex, and Somatic Symptom Disorder

Love hurts.

Posted Mar 31, 2017

“In the Spring a young man's fancy lightly turns to thoughts of love.”

As we head into the first full month of spring, as the words of Alfred Tennyson wend their way through the minds of so many young men, and women, they are often accompanied by the barely audible echoes of an unspoken risk: the risk of sexually transmitted diseases (STDs), the silent destructors that only make themselves known after the fact, when passion is replaced with, if not penitence, perhaps pensiveness.

In the realm of Public Health, those thoughts of love trade places with reality, as individuals unknowingly spread infections, or are perhaps afraid to discuss them due to their sensitive nature. Left untreated, STDs may lead to the development of serious conditions, including pelvic inflammatory disease, infertility, and ectopic pregnancies.  United States Centers for Disease Control and Prevention analyses from 2013 showed an incidence of 19 million STDs annually, with individuals aged 15 to 24 years making up almost half of newly acquired infections.

However, perhaps there is something just as crippling as an infection being transmitted sexually, but not causing vaginal discharge or penile wart.

A group in Japan has identified a variation of Somatic Symptom Disorder (SSD), one they term “4 STD,” and which they propose should be recognized as an independent clinical entity, since the presentation of this disorder is very “distinctive.”

The article on “4 STD” presents case reports:

a. A 40 year-old male who, after having had sex with a Commercial Sex Worker (CSW), developed body aches and sweats.  Numerous laboratory tests (including for HIV and hepatitis) were negative.  The individual improved with anti-depressant therapy.
b. A male patient in his 30s presented with “sputum stuck in his throat” as well as a sore throat for two years.  He had performed unprotected cunnilingus with several CSWs.  A medical evaluation was unremarkable.  With counseling, the symptoms essentially resolved.
c. A male in his 20s developed penile discomfort accompanied by a belief that there were sores in his mouth and on his penis, all this shortly after having unprotected sex with a CSW.  Again, the examination and laboratory work-up were negative.

The authors conclude that their “4 STD” may be diagnosed with the following criteria:

1. One or more somatic symptoms that are distressing or result in significant disruption of daily life, with excessive thoughts, feelings, or behaviors related to these symptoms.
2. Symptoms that occur after voluntary sexual intercourse, associated with fear of STDs.
3. Symptoms NOT associated with sexual abuse or a forced sexual relationship.
4. Organic disorders, including STDs, are excluded.


Iwata K, Katsuda Y. Somatic symptoms after sexual behavior with fear of four sexually transmitted diseases: A proposal of novel disorder. Journal of Family Medicine and Primary Care. 2016;5(3):706-708. doi:10.4103/2249-4863.197297.