By Mark Gold, MD
The French and Italians once blamed each other for the creation of syphilis, officials viewed it as a moral incentive to maintain sexual propriety, and California required cases to be reported by number rather than name to conceal the identities of “ sinful” sufferers.1 The infection often went undetected, causing neurological and psychiatric problems chronicled in the lives of the rich and famous: Eduard Manet, Paul Gauguin, Vincent van Gogh, Ludwig van Beethoven, Robert Schumann, Franz Schubert, Al Capone, Keats, Baudelaire, Dostoyevsky, and Oscar Wilde.2 Later, diagnosis and treatment changed. Advances in science and medicine, if not in the reduction of stigma, dramatically cut reported rates of syphilis,3 and public health authorities had major successes in curbing Sexually Transmitted Diseases (STDs) over the second half of the twentieth century. In 2018, 1,306 infants in the United States contracted syphilis, a 185 percent rise since 2014.
The CDC, in a recent report, is now sounding the alarm over astonishingly large increases in the prevalence of STDs. Cases have now increased for the fifth straight year and reached another all-time high. One contributing factor is substance use and substance use disorders (SUDs), which are linked to unprotected sex, sex with multiple partners, and other behaviors increasing the risk of STDs. As the CDC predicted, needle use and substance-seeking sex have had major impacts on STD rates: a 2016 report spotlighted 220 counties at elevated risk of HIV from high levels of intravenous drug use. Drinking and use of other substances, which can alter judgment and risk calculations, are also associated with increased chances of contracting STDs.
But in some STD cases, the problem is not a complex one linked to a variety of nuanced and complicatedly intertwined variables. It’s simply a function of not trying. As the CDC’s Director of STD Prevention Gail Bolan notes of infants with syphilis, “This goes beyond data and surveillance, beyond numbers and calculations—we lost 94 lives before they began to an entirely preventable infection.”4
What did this report find about STD cases?
This report found a continuation of a dramatic surge in STD cases in recent years:
Chlamydia cases rose by 19 percent since 2014.
Gonorrhea cases rose 63 percent since 2014.
Primary and Secondary syphilis cases rose by 71 percent since 2014.
Congenital syphilis cases rose by 185 percent since 2014.
Congenital syphilis is the kind that infants contract from their mothers during pregnancy. Primary and Secondary syphilis refer to stages of the disease by symptom. This report found that chlamydia is the most common STD, with 1.8 million cases in 2018. Chlamydia cases also rose by almost 3 percent since 2017. They are most common in young adults and adolescents. There were 583,405 cases of gonorrhea in the U.S. in 2018. In 2009, cases reached a “historic low”, this report observes. There were 35,063 cases of primary and secondary syphilis in 2018, marking a large increase since a historic lows in 2000-2001. These STDs are found in males and females and across different cultural groups and regions in the country. There were, again, 1,306 cases of congenital syphilis in 2018, and the number of cases for each STD has substantially spiked for five straight years, making 2018 another year of all-time highs for these diseases.
This report says that these cases aren’t just concerning because of the suffering of infected individuals, as severe as that suffering may be. We also have to worry about related health problems. Neisseria gonorrhoeae, for example, can cause infertility and lifelong pelvic pain, among other problems, and the disease has grown more resistant to treatment over time—this report warns that our healthcare system is actually “slowly running out of treatment options” for it. This report also notes that half of all reported STD cases are in individuals between the ages of 15 and 24. In addition to infertility, younger Americans with STDs can face powerful stigma and the transfer of HIV from one sexual partner to another. All of this adds up to billions in costs to our health care system. The public, this report asserts, has often ignored the severity of STDs as a public health problem, even though authorities and health care providers helped cut case rates to historic lows relatively recently in American life. Syphilis was almost eradicated. Now, sharply increasing cases are “exposing hidden, fragile, populations in need that are not getting the health care and preventive services they deserve.”
Why is this important?
Kaiser Health News explains that congenital syphilis crawls through the placenta and into the fetus, where it attacks “every part of the body.”5 Infected infants’ brains may then develop abnormalities that kill them. And surviving infants may then suffer bone deformities, organ and blood problems, debilitating pain, and blindness. Reading about the effects of congenital syphilis is difficult. Part of why this report is so important is because it highlights such a significant national scandal—congenital syphilis and its appalling consequences are easy to treat, and we’re simply not doing it. Antibiotic shots for the disease, when it’s discovered through testing during pregnancy, stop babies from getting it. Some of the increasing cases of congenital syphilis can be attributed to declining public funding for health care services delivered to low-income women. The CDC’s Dr. Bolan calls for more prenatal testing and prompt treatment, with testing for all pregnant women during their first prenatal visits, and additional testing for at-risk women at 28 weeks and then delivery. She also says that health care providers should try to get a sense of their pregnant patients’ general circumstances in life.
This last recommendation is an interesting one. If public health problems involving STDs—the associated shame and stigma, economic precariousness, lack of access to effective treatments—sound similar to those involving substance use disorders (SUDs), it’s likely because they are, but both diseases can also contribute to each other. Some patients with treatable but undiagnosed STDs, for example, may receive their only connection to health care services from MAT clinics, which may not necessarily test for other health conditions. This can lead to substantial problems across a range of issues in treatment courses for individuals with SUDs, including neurocognitive function after methamphetamine use, overlapping or additional SUDs, and patient social networks and finances. But it’s also now clear that more SUD cases, and the lack of comprehensive treatment for them, also lead to more STD cases.
Some of the dramatic increase in STD cases may be the result of better or more frequent testing and screening protocols. This report also finds additional contributing causes: stigma prevents patients from seeking testing and treatment, many patients have insecure housing and finances, and some also seem to be using condoms less.6 Few understand who is at risk, and for which STD, and for whom vaccination is recommended. Declining use of condoms is also concentrated among the young and among men who have sex with men (or MSM, an identity or orientation-neutral term), who are, along with pregnant women, at increased risk of contracting STDs. The CDC also cautions that "Anyone who has sex is at risk", but the highest risk groups are individuals between the ages of 15-24, gay and bisexual men and MSM, and individuals with substance use disorders. Even pregnant women should be aware that they are more likely to be affected.
At-risk groups, substance use, and interventions
Gay, bisexual, and other MSM have the highest rates of Primary and Secondary syphilis cases.7 MSM have also contracted more cases of gonorrhea and chlamydia in recent years. This has occurred despite the availability of effective antibiotics. The CDC recommends annual screening for all sexually active MSM and more frequent screening for those at high risk, but these efforts have not seemed to help very much.8 The data suggest that more frequent screening of MSM and MSM with multiple recent partners is needed. But it’s not enough to focus on MSM. Primary and Secondary syphilis rates among women and all men have also risen sharply.
STDs also include Hepatitis and HIV, which are also on the rise in outbreaks throughout the country, especially affecting gay and bisexual men and MSM. Sex and close personal contact spread Hepatitis A, though it can be readily stopped through vaccination. The CDC recommends that all MSM should be tested for Hepatitis B and vaccinated for Hepatitis A and B. The vaccine is also recommended for children one year or older.9 Recent reports of surging HIV rates associated with the opioid epidemic are also alarming. The CDC reminds us that drug use, drugs of abuse, and STDs, including HIV, are linked to SUDs.
The CDC also lists the links of different substances to HIV risk:
Alcohol. Excessive alcohol consumption, notably binge drinking, can be an important risk factor for HIV because it is linked to risky sexual behaviors and, among people living with HIV, can hurt treatment outcomes.
Opioids. Opioids, a class of drugs that reduce pain, include both prescription drugs and heroin. They are associated with HIV risk behaviors such as needle sharing when infected and risky sex, and have been linked to a recent HIV outbreak.
Methamphetamine. “Meth” is linked to risky sexual behavior that places people at greater HIV risk. It can be injected, which also increases HIV risk if people share needles and other injection equipment.
Crack cocaine. Crack cocaine is a stimulant that can create a cycle in which people quickly exhaust their resources and turn to other ways to get the drug, including trading sex for drugs or money, which increases HIV risk.
Inhalants. Use of amyl nitrite (“poppers”) has long been linked to risky sexual behaviors, illegal drug use, and sexually transmitted diseases among gay and bisexual men.
Methamphetamine use is also particularly linked to syphilis. The U.S. has an opioid epidemic and a methamphetamine epidemic, though focus remains more on the former.10 The CDC has traced methamphetamine use to STDs, HIV, and Hepatitis clusters. Critically, services to combat and treat SUDs and STDs have to work together if we’re to successfully reduce the incidence of syphilis.11 People who inject drugs (PWID) are also at increased risk for Hepatitis and HIV, and condoms, which are used to prevent many STDs, don’t stop Hepatitis A.
Recent data shows lower condom use among women and men who had two or more partners in the past year, so it’s important to ask non-judgmental, precise, and detailed questions about sexual behavior to estimate risks and help both prevent and treat STDs. Prevention and education are important, but we shouldn’t forget vaccinations, examination and testing frequency, interventions, and telemedicine. The lack of an effective concerted national effort on this issue has led to the use of crowd diagnosis and second opinions on social media.12 Crowd-sourced diagnoses are a novel approach. They can be rapid and delivered through anonymous response, but initial diagnoses and second opinions are better suited to Board Certified MDs: the relevant conditions can be very complicated, and misdiagnosis could inadvertently cause more disease transmission and delay appropriate treatments. And others viewing a post may wrongly self-diagnose their own conditions. We’re well past the point at which authorities thought that treating STDs was misguided because they incentivize morally appropriate behavior in the bedroom, but that’s all the more reason for these cases to shock us, and for the CDC to raise the alarm.
Peterman, T.A. (2009) Sex, Sin, and Science: A History of Syphilis in America. Emerg Infect Dis
Tampa, M., Sarbu, I., Matei, C., Benea, V., Georgescu, S.R. (2014) Brief History of Syphilis. Journal of Medicine and Life
Bakalar, N. (January 21, 2019) A Rising Threat to Pregnant Women: Syphilis. New York Times
Bolan, G. (October 8, 2019) CDC’s “State of the Union” on sexually transmitted diseases (STDs) in the United States stresses that we must stop syphilis — too many babies are needlessly dying. Retrieved from https://www.cdc.gov/std/dstdp/2018-SR-DCL_FINAL.pdf
Barry-Jester, A.M. (October 8, 2019) Congenital Syphilis Continues To Rise At An Alarming Rate. Kaiser Health News
Centers for Disease Control and Prevention (CDC), NCHHSTP Newsroom. (October 8, 2019) New CDC Report: STDs Continue to Rise in the U.S. Retrieved from https://www.cdc.gov/nchhstp/newsroom/2019/2018-STD-surveillance-report-press-release.html
Kidd, S.E., Grey, J.A., Torrone, E.A., Weinstock, H.S. (2019) Increased Methamphetamine, Injection Drug, and Heroin Use Among Women and Heterosexual Men with Primary and Secondary Syphilis - United States, 2013-2017. CDC, Morbidity and Mortality Weekly Report
Weiss, K.M., Jones, J.S., Anderson, E.J., Gift, T., Chesson, H., Bernstein, K., Workowski, K., Tuite, A., Rosenberg, E.S., Sullivan, P.S., Jenness, S.M. (2019) Optimizing Coverage vs Frequency for Sexually Transmitted Infection Screening of Men Who Have Sex With Men. Open Forum Infect Dis
CDC. (Reviewed 2019) Viral Hepatitis And Men Who Have Sex with Men. Retrieved from https://www.cdc.gov/hepatitis/populations/msm.htm
Dembosky, A. (2019) Meth Vs. Opioids: America Has Two Drug Epidemics, But Focuses On One. Kaiser Health News
CDC. (Reviewed November 2019) People who Inject Drugs and Viral Hepatitis. Retrieved from https://www.cdc.gov/hepatitis/populations/idu.htm
Nobles, A.L., Leas, E.C., Althouse, B.M., et al. (November 5, 2019) Requests for Diagnoses of Sexually Transmitted Diseases on a Social Media Platform. JAMA
1. CDC. (2019). Sexually Transmitted Disease Surveillance 2018. 2018. U.S. Department of Health and Human Services. Retrieved from https://www.cdc.gov/std/stats18/STDSurveillance2018-full-report.pdf
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.