Pubic lice infestations are not a reportable condition in the US, but are considered an STD. There have been reports of outbreaks of pubic lice during earlier decades [1], though reports are not numerous. In countries where military or STD records are widely available, records are more common. Mimouni [2], for example, describes two outbreaks found in Israeli army records during the years 1972–1999. Incidence of pubic lice in European and South American STD clinic records and prison health records have been reported sporadically [3–5]. Though reporting on pubic lice is less frequent than head lice or body lice, its epidemiology is important because of correlation with the occurrence of other STD infections [2,6–8]. Because there is evidence of co-occurrence with other STD infections, and because accurate surveillance of ectoparasite levels is valuable in evaluating emerging or changing trends, this study was undertaken to describe self-reported attitudes and behavior concerning lice prevention and treatment (and treatment myths) which will add to the general knowledge of Pthirus pubis infestation in young adults. It will also help alert college health clinics and health education providers to the need for continued educational efforts about this pest.

Table 2 is the list of questions administered to 817 college students regarding pubic lice. The results in the table include answers of 782 students who self-reported no experience with pubic lice or STDs. The survey population comprised both male and female students. Ninety-five percent were ages 17–23. Male students made up 35% of the respondents, and female students 65%. Eleven out of 817 students who answered all 26 pubic lice questions had self-reported experience with pubic lice infestations (1.346%). Thirty-two out of 817 students had self-reported experience with STD infection (4%). Some of these had both STD and pubic lice experience and a few only pubic lice experience. Male students reported more experience with pubic lice and females with other STD infection (Figure 2).

Attitudes about environmental treatment for pubic lice included mostly positive responses to all suggested actions. For actions involving pesticides, however, negative responses increased (Table 2). Attitudes regarding transmission of pubic lice elicited generally positive answers for all of the possibilities listed, including using a toilet seat after someone who was infested. Negative answers were highest for living with but not sleeping with a person who was infested. Responses to the questions listing possible symptoms resulted in positive responses for all descriptions, including symptoms of swollen genitals, and vaginal or penile discharge (Table 2). The two symptoms with the most positive responses were itching in affected areas and evidence of lice eggs on pubic hair.

Self-treatment questions including bathing in Lysol or bleach water were answered positively by some students. Use of hydrocortisone on bites and taking of antibiotics were the two self-treatments, in addition to discontinuing intimate contact, were answered positively most often.

Low levels of pubic lice incidence (nearly 2%) in a sexually active population is within the expectation of a group of young adults as indicated in recent literature of STD clinic surveys. Attitudes and knowledge about treatment and symptoms suffer from persistent myths and misinformation, however. Some students recorded a negative reaction to pesticides as a treatment for ectoparasites. This eliminates the only effective treatment for killing lice other than mechanical removal. Use of shampoos or crèmes containing pyrethrin pesticides is recommended to prevent the spread of these ectoparasites [9]. Physical removal of all insects and eggs is difficult to accomplish, but would be effective if completely thorough.

A second source of myth and possible stigma is peer group misinformation about pubic lice behavior and transmission. Students regarded environmental contact with toilet seats and clothing after an infested person as dangerous. Since pubic lice are extremely sedentary and seldom leave close contact with the body, transmission through either objects or clothing is highly unlikely [8]. Close intimate contact or “skin to skin” contact is the main source of transmission.

Symptom misconceptions appear to be the source of most confusion. Since these students have little experience with pubic lice infestations, non-specific symptoms such as fever and a generalized rash were considered viable, though itching and evidence of lice eggs were decisive favorites and legitimate diagnostic symptoms.

Answers to treatment option questions showed negative attitudes toward an effective treatment with pesticide creme. The positive choice of antibiotic treatment, an ineffective treatment, interestingly exceeded even the choice of fever as a symptom, which might warrant the use of antibiotics (80% chose antibiotic use and 32% chose fever as a symptom). Discontinuation of contact with current sexual partner was the overall choice action for prevention.

Limitations of this study included the use of student populations of different ages in college classes as the study group. The older, returning adult students, skewed the average age of students who had experience with STD infection. The small number of students with self-reported experience of pubic lice or STD infection prevented generalization or characterization of students with experience. Self-reported data often includes inaccurate or dishonest answers, which affects incidence characterization and generalizations. Extrapolation of the results of this study to the general public thus may be limited since the subjects were all students who volunteered to answer the survey. To ensure IRB standards, students were given the option to omit some of the questions, and surveys with omitted questions were not included in the final tabulations Some bias in the results may have occurred as a result of this; however, the incomplete questionnaires were not a systematically related group according to the overall demographic data which all students did complete.

An online survey was administered to college students taking a basic health course at a mid-sized East Coast University to determine their knowledge, experience and attitudes about pubic lice infestations, prevention and treatment. Students volunteered to complete the survey, and also had the option to omit any questions they did not wish to answer in the survey if they chose to participate. Incomplete surveys were not counted in the analysis. Access to the results of the survey was restricted to faculty members who obtained University IRB review for the questions (UMCIRB#07-0590), and who were trained in IRB methodology. Only students in the class had access to the survey through the campus server. Students who chose to answer the survey as part of their class work were issued a receipt to print, with the time and date of completion recorded. Completion was verified by instructors in each of the student’s class sections. Results without individual identification were sent to researchers through university computer servers.

In an article surveying stigma and shame related to STD infection, Lichtenstein [21] reported that pubic lice were the least stigma and shame eliciting STD among seven others, including HIV, syphilis, gonorrhea, genital warts, genital herpes, and Chlamydia. It is possible that since the advent of HIV as a fearful world-wide scourge, pubic lice and other STD infections have lost significance, importance or stigma in the list of consequences from risky sexual behavior. Ectoparasitic population dynamics should still be a concern of health scientists, however, in this current climate of worldwide human population homogenization from travel and collaborative work. In an increasingly homogenous world, Pthirus pubis has a potential for new outbreak emergence, especially with its increased resistance to pesticides. Its cousin, Pediculus humanus humanus is a vector of disease, so pubic lice and other lice population and infestation statistics cannot safely be ignored. Pubic lice especially warrant attention and continued inclusion in health education for young adults because of their relation to STD infection, and their classification as a sexually transmitted disease. Serious attitude and knowledge misconceptions such as the overwhelming approval of antibiotic use for treatment of pubic lice need to be addressed.