Below are some answers to common questions or misconceptions my clients diagnosed with herpes often ask or talk with me about in therapy sessions. I hope these are helpful to you as you process your feelings and thoughts about your diagnosis.
Isn’t Genital Herpes Type 2 Herpes?
Many people assume that because they have genital herpes that they have type 2 herpes. However, there are two types of genital herpes: Herpes Simplex Type 1 and Herpes Simplex Type 2. Type 1 genital infections are increasing. The only way you can be sure which type you have is through testing (which I’ll talk about later in this post). You cannot tell the difference by looking at the symptoms. Some people think the severity of the first outbreak is predictive of whether it’s type 1 or type 2. Nope. An outbreak of type 1 and type 2 can look the same in appearance. Type 2 does tend to cause more frequent genital outbreaks than type 1 in people who get symptoms.
Most people who have herpes don't recognize symptoms, although once taught, many of these individuals can learn to identify them. People who do experience symptoms tend to get fewer and milder outbreaks over time. Terri Warren, ANP, who is an expert in the field and has lots of experience diagnosing and treating patients with genital herpes, reports that the first year is when the virus is most active and is not a good indicator of outbreaks long-term.
If you are someone who gets symptoms, you are definitely not alone. I see many clients, mostly young women, in my practice who also have symptoms.
Can I Transmit If I Don’t Have Symptoms?
This is probably one of the most frustrating things about herpes. Yes, you can still transmit when you don’t notice any symptoms. With herpes, there is viral shedding, meaning the virus is coming to the surface of the skin without producing recognizable symptoms. Most transmissions occur when people don’t recognize symptoms. Herpes is transmitted through sexual contact with the affected area (intercourse, oral sex, rubbing together of genitals without clothes on). Oral herpes can be transmitted to someone else's lips during passionate kissing when there is asymptomatic shedding or kissing during an outbreak.
Is It Possible My Partner Didn’t Know They Had Herpes?
Yes. If your partner tells you they didn’t know they had herpes, it’s quite likely that they really didn’t know. This is so important because when one partner has a first outbreak, it’s easy to assume the other lied or cheated. Unfortunately, herpes is just not a reliable detector for lying or cheating in a relationship. You will have to use some other method to determine whether your partner is trustworthy. It’s also important to know that you can be in a relationship for years before herpes pops up. In addition, if your partner has type 1 oral herpes (which is very common) and you don’t have type 1, even if your partner hasn’t had a cold sore since childhood, they can still transmit herpes to you through asymptomatic viral shedding. Many people don’t realize that they can transmit oral herpes to their partners genitals when they don’t have a cold sore and this can be very surprising for couples when it happens.
Is Knowing What Type I Have Important?
Knowing what type you have is important because if you have a partner who has the same type, it will be very unlikely that you would transmit to each other in a different location. For instance, if your partner has type 1 on the mouth and you have type 1 genital herpes, you both have antibodies to the type 1 virus. This means you wouldn’t have to think about giving each other herpes in a different location. And since so many people don’t know they have herpes, having your partner get tested can be valuable. Herpes isn’t included in most standard STD testing, so even if your partner has been tested for STDs, there’s a good chance they weren’t tested for herpes. If your partner gets tested, you may find that they have the same virus and type that you do and they just never knew it. If so, this will likely change the conversation you and your partner have about reducing risk of transmission. There are some caveats about blood tests in individuals with no symptoms that you need to know, however, which I will talk more about later in this post.
Can You Pass Genital Type 2 to Your Partner’s Mouth Through Oral Sex?
This question is asked a lot. Yes, it is possible, but type 2 oral infections are uncommon. For some reason, the mouth is not a site of preference for type 2. When type 2 does occur on the mouth, it looks just like a cold sore and it rarely recurs and very rarely sheds virus.
Can I Still Have Babies?
Many women worry that having herpes means they won’t be able to have a safe pregnancy and birth. I hope it comforts you to know that neonatal herpes is very rare. Most women with herpes are able to have a vaginal birth and deliver with no complications with herpes. Contracting herpes in the 3rd trimester creates the most significant risk. The antibodies you develop by having herpes prior to pregnancy contribute significantly to protecting your baby. Partner with your doctor when the time comes to reduce any risks. You can also read this piece about one woman’s experience of herpes during pregnancy and delivery.
Can I Reduce the Risk of Transmitting to My Partner?
Yes. It’s great that you are informing yourself about your diagnosis because you can do a few things to reduce risk to your partner: 1) The most important thing you can do is to get to know your body and learn about your symptoms as well as the sensations you experience just before you see symptoms. Abstain from sex from the time you notice those sensations to the time any lesions have healed. 2) Use condoms. Condoms aren’t 100% protective, but they do reduce risk significantly. 3) Take daily antiviral medication, known as suppressive therapy. One important study showed that daily Valtrex reduced the risk of transmission for people with recurrent type 2 by almost 50%.
Some partners choose to only avoid sex during outbreaks while other partners choose to combine all three precautions. Many long-term partners eventually choose to forego condoms. Most of my clients who use suppressive therapy have reported success in avoiding transmission. Either way, I think relationships work best when partners are aware of and comfortable with the risk.
What Should I Know about Testing?
If you have an outbreak, hopefully your doctor will swab and type it to determine if it's 1 or 2 using a PCR test, which has less chance of a false negative than a viral culture. If your doctor does an IgG based blood test at the same time as your first outbreak, it can help you sort out whether this is a new infection or an old infection (if the swab comes back positive and the blood test comes back negative for the same type, you are likely still building up antibodies which would mean this is a recent infection). But if you don’t have symptoms, you can seek out a blood test. Blood tests are tricky though and it’s very important to be informed about what the results mean. I always recommend that patients get a copy of their results.
The most common and accessible test is the HerpesSelect IgG based test. You don’t want an IgM based test. Some doctors still use them but the CDC recommends against their use in diagnosing herpes. When the HerpesSelect came on the market it was so helpful to many people who had herpes as they could find out if they had type 1 or type 2. The unfortunate thing is that there are problems with false positives for type 2 and false negatives for type 1. Most of the false positives for type 2 have a positive result value between 1.1-3.5 and a large number of those that fall into that range do turn out to be negative. Many doctors don’t have this updated information and diagnose their patients with herpes even when results are in this low positive range. (Keep in mind, if it has been less than 3 or 4 months since exposure, antibodies may still need time to rise.) If you or your partner have a positive result in that low range and don’t have symptoms or have atypical symptoms, it’s important to get confirmatory testing. The best confirmatory test is the Western Blot. It is not currently (as of Jan 2017) accessible in NY. You may have to travel to a nearby lab in another state (such as NJ) to get your blood drawn for the test. There has been a lot written about testing and if you are confused about your results or want to pursue confirmatory testing, I recommend reading the “Diagnosing Herpes” section in the Free Herpes Handbook written by nurse practitioner and herpes expert, Terri Warren.
In someone without symptoms, a positive type 2 blood test is assumed to be genital herpes. In someone who has never had symptoms, a positive type 1 blood test cannot determine the location of infection. If you do have symptoms, don’t simply settle for a visual diagnosis. Visual diagnoses can be unreliable and clinicians have diagnosed things as herpes that are not herpes.
I’ll be continuing this series over the next few weeks, including a post about how to start the conversation. If you find these posts helpful, you can sign up to receive notices about blog posts here.
Other Posts In This Series
For More Help and Information
Supporting women with herpes here in New York City is a strong area of interest of mine as a therapist. I do make a point to stay up-to-date, however, I am not a medical expert. If you want to learn more in depth about the topics above, I highly recommend the Free Herpes Handbook, written by nurse practitioner, Terri Warren.
Please remember that we are continuously learning new things about herpes. I will try to keep this list updated but remember that research may come out today that changes what we currently know about herpes. Information on this website is not intended to substitute professional medical or psychotherapeutic advice.