After reaching historic lows more than a decade ago, rates are on the rise again.
Last month, the Centers for Disease Control and Prevention released its latest data on cases of sexually transmitted infections during the first year of the pandemic. In the early months of 2020, the number of people diagnosed with gonorrhea and syphilis declined, as you might expect — it was, after all, a time of extreme isolation for many. Subsequently, though, infection rates surged so much that by the end of the year, the case counts were 10 percent and 7 percent higher than in 2019. In total, there were some 134,000 reports of syphilis and 678,000 reports of gonorrhea. These were “stunning” increases, says Hilary Reno, an associate professor at the Washington University School of Medicine and medical director of the St. Louis County Sexual Health Clinic. “I can’t tell you how many primary-care physicians have called me recently and said, ‘I just saw my first-ever case of syphilis this year.'”
Indeed, syphilis was nearly eradicated in the United States around 2000; gonorrhea reached its lowest rates of infection in 2009. Many doctors who began practicing during that period haven’t had experience diagnosing these S.T.I.s, particularly in their female patients. According to Ina Park, a professor of family and community medicine at the University of California, San Francisco, “There’s an entire generation of physicians and clinicians who had never seen syphilis in women and babies before.”
This is a significant problem: S.T.I.s can irrevocably damage the reproductive system. At least 20,000 women are rendered infertile by untreated S.T.I.s in the United States each year. Syphilis can cause sores and rashes and, if untreated for decades, fatal damage to the brain, heart and other organs. Gonorrhea can be painful and may result in pelvic inflammatory disease in women. Each condition is caused by bacteria and can be cured with antibiotics (though drug-resistant strains of the bacterium that causes gonorrhea are on the rise). Unfortunately, they are often asymptomatic, especially in women, and for them it can be harder to see signs of infection and easier to mistake some of those signs as normal discharge or yeast infections.
The ease with which S.T.I.s spread undetected makes it crucial to screen for them regularly. Yet that is not happening. “The pandemic made S.T.I.s worse in America — for the first year, people all but stopped getting testing and treatment,” says David C. Harvey, executive director of the National Coalition of S.T.D. Directors, a trade association for state and local S.T.I. Health Department programs that collected its own data during the pandemic. (The C.D.C. data comes from a national surveillance system that includes mandatory lab reporting and sample surveys.) Moreover, contact tracers, assigned to notify sexual partners of exposure, were redeployed to focus on Covid.
Historically, the highest rates of syphilis have been among gay and bisexual men, then among heterosexual men. And while that is still true, cases among gay and bisexual men have risen more slowly in recent years and even declined slightly in 2020. Cases among heterosexual women, on the other hand, increased 30 percent from 2018 to 2019 and 21 percent from 2019 to 2020, jumps that experts attribute in part to the increasing prevalence of opioid and methamphetamine abuse, which makes risky sexual behavior — transactional sex, condomless sex — more likely among all genders.
Credit…Illustration by Ori Toor
This trend among women has fueled a corresponding surge in syphilis among newborns. In 2020, there was a nearly 15 percent increase in congenital syphilis — amounting to a 235 percent increase from 2016. Congenital syphilis can lead to severe lifelong health complications and stillbirth; of 2,148 infants who contracted syphilis in 2020, 149 did not survive. When women who are engaging in substance abuse become pregnant, they frequently avoid prenatal care for fear of being drug-tested and potentially losing custody of the child. That means many of them aren’t tested for syphilis and don’t receive the treatment that would prevent their baby from getting it. The C.D.C. recommends testing for the infection at the first prenatal visit and, for women who test positive or are at increased risk, early in the third trimester as well as at delivery. (Most states require doctors to perform the initial test, but only 19 also require screening in the third trimester.)
Perhaps the simplest explanation for the overall rise in S.T.I.s between the 2000s and now is that lawmakers reallocated funding to other problems deemed more dire. Many S.T.I. clinics that provided free or low-cost testing and treatment closed or scaled back hours. Other factors contributed to the problem. The growth of online dating expanded sexual networks. The ability to prevent H.I.V. infection with prophylactic medication reduced the inhibitions against having sex without a condom. And most states still do not provide comprehensive sex education. If they did, more people would know that it’s important to treat S.T.I.s and not wait, says Whitney Irie, a lecturer in population medicine at Harvard Medical School. As it is, a popular impression is that S.T.I.s are “essentially obsolete,” she says. “I don’t think there’s a clear understanding, especially among people with a uterus, of the long-term impact on your reproductive organs. There’s this casualness about it that lends itself to being casual about preventive measures.”
Reducing the burden of S.T.I.s will require outreach, particularly for marginalized groups, including women, people in the L.G.B.T.Q. community, Native Americans and Alaskan Natives and people of color, all of whom suffer disproportionately high rates largely because the health care system has neglected them. Black women, for example, have rates of syphilis, gonorrhea and chlamydia that are as much as seven times that of white women, and they face additional hurdles to receiving sexual health care. Black women, Irie says, must also contend with the “perceived stigma and perceived shame from their community” that receiving sexual health care means you don’t share its values, such as female monogamy. That’s a stereotype applied to women across many demographics.
To reach those who have been disenfranchised, providers need to be trained to offer sexual health care to patients who have experienced historical trauma and sexual trauma, including assault and abuse. “If they’re met with a system that doesn’t use open terminology or doesn’t recognize their trauma, their experience can be horrible,” Reno says. “We can retraumatize them, and they don’t come back ever.”
Public-health initiatives have also succeeded by partnering with local institutions people trust. In St. Louis, which has some of the nation’s highest rates of S.T.I.s, many barbershops and beauty salons offer testing information and free condoms; elsewhere, projects in partnership with churches have been able to increase mammograms and H.I.V. testing among Black women. Half of all new S.T.I. infections are among 15-to-24-year-olds, but school-based health centers that offer comprehensive health services on campus have been shown to improve attendance and graduation rates and decrease urgent-care visits.
The pandemic has interrupted countless health services. But it also generated solutions. For example, in March 2020, a program called TakeMeHome began mailing out free H.I.V. self-test kits, with a focus on reaching gay and bisexual men. Half the recipients had not been tested within the previous year, and more than a third of them had never been tested at all; after using the kit, more than 10 percent reported accessing other sexual-health services. “You have to make it as easy for people as possible,” Park says.
If you’re sexually active, you will inevitably be exposed to pathogens, just as you are by shaking hands with or breathing the same air as others. “Your clothes are off,” Park says. “That’s the only difference.” S.T.I.s “are not a personal failing,” Reno says. “This is a systemic societal challenge.” Thus, talking openly about sexual health care stands to benefit everyone. Park recommends pressing your provider for testing; ideally, S.T.I. screening would be treated like a trip to the dentist. “Put it in your routine as something you do regularly.”
Kim Tingley is a contributing writer for the magazine.