The dirty little secret: STD increases

July 1, 2017

It’s a dirty little secret – one no one really wants to talk about, but one that is putting our nation’s teens and young adults at risk of chronic pain, infertility, lifelong health issues – and even death. It’s the scourge of sexually transmitted diseases (STDs), which have reached such record heights that experts believe that fully half of the population of those aged 15 to 24, which numbers about 110 million men and women in the United States, are afflicted with chlamydia, gonorrhea, syphilis, human papilloma virus (HPV), HIV, and other sexually transmitted infections, with up to 20 million new infections each year.

And in the last couple of years, health officials have seen a jarring jump in infection rates.

“According to the Centers for Disease Control and Prevention (CDC), in August 2016, they had their highest numbers in recorded history of chlamydia and gonorrhea. It’s very troubling,” said Mary Anne Mosack, executive director of Ascend in Washington D.C.

According to the CDC, in 2016, 70 percent of those aged 15-24 who were sexually active had been infected with gonorrhea; 63 percent had been infected with chlamydia; 49 percent with HPV; 45 percent with genital herpes; 26 percent between 13 and 24 had been infected with HIV; and 20 percent had syphilis.

It was the second consecutive year where the CDC reported what they termed “alarming” and “troubling” increases in STDs in America. The CDC reports reflect numbers reported from the year prior. The 2015 report noted that chlamydia hit a record high in 2014 of 1,441,789 cases, or five out of every 1,000 people. It was also a 2.8 percent increase over 2013. Reported gonorrhea cases in 2014 rose to 350,062, which was an increase of 5.1 percent from 2013.

But the biggest shock was that primary and secondary syphilis cases had increased 15 percent from the year before, and congenital syphilis increased a full 27.5 percent. In Michigan, syphilis increased by four percent from 2015 to 2016, with a nine percent increase in males diagnosed. More disturbing is that there was an 18 percent increase in males diagnosed with syphilis aged 15 – 24, and a 23 percent increase in men who have sex with men aged 15 – 24, according to the Michigan Department of Health and Human Services (DHHS).

The CDC explained that syphilis is a sexually transmitted infection that is divided into stages, primary, secondary, latent, and tertiary, with different signs and symptoms associated with each stage. It can cause very serious health complications when left untreated, but is simple to cure with the right treatment. 

Many, both young and older, straight and gay, were under the misguided – and false – assumption that these STDs were something that had been left in the past. But the past has reared its ugly head, whether because many STDs and STIs (sexually transmitted infections) have little to no symptoms; the pervasiveness of the “hook up” and Tinder culture; to the misguided belief that a condom can always protect them. 

“Lots of people don’t have symptoms, so they don’t know they have one, and they pass it on,” said Evelyn Van Sloten with Sexual Health and Relationship Education (SHARE) organization, part of Crossroads Care Center, which has educators going into local school districts to augment their health and sex education programs. “Many (infections) are carried on the skin, so just by any kind of touch or stimulation, they pass it (herpes, HPV, some syphilis) on. Plus, many condoms just don’t cover enough area.”

The National Coalition of STD Directors (NCSD) warns that women and girls are biologically more susceptible to contracting an STD, but often experience few or no symptoms when they do get one, where the consequences of leaving it untreated can include infertility, pregnancy complications, cervical cancer, pelvic inflammatory disease, and an increased risk of HIV transmission. Pregnant women who contract an STD are at higher risk of miscarriage and premature delivery, and can transmit the infection to their baby during pregnancy and birth.

Among young adults aged 15-24 and homosexual and bisexual men, who are at greatest risk of STDs, there tends to be a great ignorance of the diseases themselves, and how they can contract them. Couple that with an age group that is more willing to take risks, and there are the ingredients for skyrocketing STD rates.

NCSD said that is often because of the emphasis on “abstinence-only-until-marriage education in schools, coupled with a lack of communication on STDs with health providers and parents often leaves young people with little accurate information on STDs and how to protect themselves.” 

Many have no idea what they have even if they do have a symptom or a sore, signs of an infection. 

Syphilis is caught via direct contact with a syphilis sore during vaginal, anal or oral sex. “A person with primary syphilis generally has a sore or sores at the original site of infection. These sores usually occur on or around the genitals, around the anus, or in or around the mouth,” a CDC fact sheet stated. “These sores are usually (but not always) firm, round, and painless. Symptoms of secondary syphilis include skin rash, swollen lymph nodes, and fever. The signs and symptoms can be mild, and they might not be noticed. During the latent stage, there are no signs or symptoms. Tertiary syphilis is associated with severe medical problems and is usually diagnosed by a doctor with the help of multiple medical tests. It can affect the heart, brain and other organs.”

Gonorrhea can affect both men and women, and can cause infections in the genitals, rectum and throat. “It is a very common infection, especially among young people ages 15-24 years,” said the CDC.

In Michigan, DHHS showed a 21 percent increase in gonorrhea from 2015 to 2016, with a 12 increase of males diagnosed in gonorrhea between the ages of 15 and 24, and 12 increase of males as a whole. 

Some men and most women have no symptoms, while others have burning when urinating. Some men will have a white, yellow or green discharge, and/or painful or swollen testicles. 

For women, it can often be confused as a bladder or vaginal infection as symptoms, if they have any, can include a painful or burning sensation when urinating, increased vaginal discharge, and vaginal bleeding between periods. It can be easily treated with medication, although drug-resistant strains of gonorrhea are increasing, the CDC said. 

But if gonorrhea is left untreated, it can cause serious and permanent health problems for both sexes, such as pelvic inflammatory disease in women, ectopic pregnancies, infertility, and long-term pelvic and abdominal pain. In men, gonorrhea can cause a painful condition in the tubes attached to the testes, which in rare cases can cause a man to be sterile. 

Chlamydia is the most frequently reported infectious disease in the United States, the CDC reported in 2015, affecting both men and women, with serious ramifications including permanent damage to a woman’s reproductive system. Both sexes often experience a lack of symptoms, and need to be tested in order to determine if they have the infection.

“We have seen no significant change in chlamydia (from the national figures),” said Jennifer Eisner, public information officer for Michigan DHHS, indicating the rise is similar here in Michigan.

“I see a lot of chlamydia and gonorrhea in young women, and chlamydia much more,” said Dr. Renee Horowitz, a Bloomfield Township obstetrician/gynecologist with Michigan Women’s Health in Farmington Hills. “We know there is a rise in syphilis as well, but that is much more among men, both gay and bisexual. All of these diseases, as well as HPV, can have significant consequences to female health, like infertility.

“Chlamydia and gonorrhea can infect the fallopian tubes and ovaries, and can become septic from a pelvic abscess,” Horowitz continued. “Often a woman doesn’t know she has (an STD) until something bad happens. It can present with pelvic pain and fever, and leads to pelvic inflammatory disease.”

Terry Ryan, director of MAC Health program, Matrix Human Services (formerly Michigan AIDS coalition), said that two years ago they added integrated testing for syphilis, gonorrhea, chlamydia, and hepatitis C, which is more AIDs specific. 

“We have been testing for HIV since 1988, going into bars, clubs and bathhouses,” Ryan said. “Two years ago, we received funding from three foundations to test for sexually transmitted infection testing in these kinds of venues where those engaging in risky behaviors congregate, and it’s proved successful. 

“We’re seeing frequent positive testing for gonorrhea and chlamydia – increases in those numbers – but also for syphilis, in the last few years,” Ryan said. “Syphilis is increasing in major urban areas I think, for a combination of reasons. It’s often a co-infection with HIV or chlamydia or gonorrhea. HIV isn’t in the news anymore. We’ve gotten good drugs, but if you’re not using condoms or having multiple sexual partners, you’re still at risk. Younger people don’t have the perspective or fear of HIV today. We still get about 50,000 new HIV cases a year.”

Horowitz said she concurs with the recommendations of the American College of Obstetricians and Gynecologists, along with the CDC, to screen all women for chlamydia and gonorrhea from the time of sexual activity to age 25, “and of course anyone who may be involved in high risk behavior at any age.”

Ryan agrees, noting they offer free and confidential testing services at numerous sites and times, including working with Affirmations in Ferndale. Oakland County Health Department has testing services five days a week at two sites.

“The CDC’s STD surveillance provides us with a snapshot of what’s happening with chlamydia, gonorrhea and syphilis in the U.S.; but it doesn’t tell us why certain trends are occurring,” said Donnica Smalls from the CDC. She said the data tells them, “We know this is the second year in a row that all three reportable STDs have increased substantially; we also know increased rates in recent years have been largely driven by men; and youth aged 15-24, as well as gay, bisexual, or other men who have sex with men (or MSM) continue to be at the greatest risk for STDs.”

“We have been seeing increases mirroring the statewide trend,” said Dr. Pamela Hackert, M.D. MPH, chief of medical services, Oakland County Health Department, with gonorrhea and chlamydia rates increasing, with a slight dip in syphilis cases. “We saw a significant increase (in syphilis) in 2015 for Oakland County and Michigan, but the preliminary data is looking good for 2016 for Oakland County.”

Hackert said the STD rates are highest among young adults in the 15-24 age range because “It’s easy to meet people over social media via dating apps, but also people at that age are going through rapid changes, and that means meeting different people. It’s the availability of dating apps and social media that the rates are so high.”

In return, Hackert said that Oakland County Health Department reaches out through social media to educate them of the dangers of STDs. 

“We also use social media sometimes to discretely contact people, to let them know they should get tested,” she said.

“We think that with the advent of social media and access to the internet that young people would have all of the knowledge and information to make informed decisions,” noted Evelyn Van Sloten of SHARE. Instead, she said, “there’s a void. Kids are still getting pregnant, and kids are at risk for STDs. With the increase in social media, they believe that risky behavior and its consequences won’t happen to them. Further, in any age demographic, a lot of people are naïve to the risks of sexual behavior.”

Sharing – and oversharing – on social media, sexting, casual sexual encounters, hooking up, the use of Tinder – all are a part of a culture that de-emphasizes relationships and highlights the carefree sexuality often seen on TV and movies. Imagine watching the bed-hopping on “Sex in the City,” and hearing Carrie and Samantha talking about their chlamydia infections, or the guys on “Entourage” discussing having caught syphilis – wouldn’t have been quite as entertaining. But teens often can’t distinguish the difference between television and real life.

“In real life, there are consequences, so we talk about consequences. We’re about having all the information. Real life is consequences, and STDs are part of that information,” Van Sloten said. “In this country, 79 million people are infected (with STDs). It translates to 27,397 (infections) every day, and 1,142 every hour. Teens contract a STD every day. It’s important (for teens) to understand the risks of sexual activity. You can’t act on feelings. We’re about teaching to avoid poor judgement calls and to make wise choices.”

What is the best way to educate teens and young adults about the risks of sexually transmitted diseases and infections? All educators and advocacy agencies agree that parents and trusted adults are the first line of communications, but in a world with rapidly changing information, they are usually not the only destination. Local school districts provide information through sex education classes, to varying degrees depending upon the district.

According to the Michigan Department of Education, by Michigan law, school districts are required to teach about dangerous communicable diseases, including, but not limited to HIV/AIDS, at least once a year at every building level (elementary, middle, high school), but school districts can choose to teach sex education. If they choose to include that as part of their curriculum, they must have a sex education supervisor and an advisory board, and at least half its members must be parents. In Michigan, instruction in HIV/AIDS and sex education must stress that abstinence from sex is a responsible and effect method of preventing unplanned pregnancies, and is the only way to 100 percent protect from sexually transmitted disease and HIV/AIDS.

“The health and well-being of our students is always our top priority. Our health education curriculum, like our general education curriculum, is designed to give students the knowledge and skills to succeed, now and in the future,” said Carrie Lawler, executive director for secondary education at Rochester Community Schools. 

Rochester Schools bases their school health curriculum on the Michigan Model for Health, Lawler said, which “enables us to address behaviors which may affect a student’s health and well-being with age-appropriate instructional activities.”

The first time students are introduced to the subject is in fifth grade, with HIV instruction, with discussion over the definition of HIV and AIDS, and how to protect themselves and others, what it is and how it is transmitted, and the importance of compassion for those who are ill.

Then, in twelfth grade, during their reproductive health/human sexuality and HIV/AIDS section, besides learning fertilization, fetal development and birth, students discuss the short-term and long-term consequences of safe, risky and harmful behaviors; “analyze how sexual abstinence is the best, safest, and healthiest choice to prevent pregnancy and sexually transmitted infections and protect one’s emotional health; and understand that condoms and other contraceptives may reduce the risk of pregnancy and some, but not all, sexually transmitted infections,” said Lori Grein, community relations director for the district. 

They also learn techniques for refusal, negotiation, and collaboration skills to avoid potentially harmful situations, such as dating violence.

Grein said the sexually transmitted infection lessons are taught by the SHARE organization. Birmingham Public Schools also utilize instructors from the SHARE organization, but only for middle school instruction, Van Sloten said. According to Brian Hafner, health and physical education teacher for the Birmingham district, information about STDs are taught in high school to juniors and seniors.

Bloomfield Hills Schools high school students have a three-day unit as part of their health curriculum, which is an “abstinence-based unit, emphasizing healthy relationships while identifying the consequences of a teenage pregnancy and sexually transmitted infections. (It includes) lifetime learning of birth control methods and the development of a healthy pregnancy, labor, and delivery,” said Shira Good, director, communications and community relations, Bloomfield Hills Schools. As for information regarding STDs, “They are taught the symptoms, and how STIs are diagnosed and treated by a doctor. Students are taught that oral sex is sex, and can cause STIs in the oral area, including cancer from the STIs.”

According to Mary Anne Mosack of Ascend, which provides resources and educates policymakers and community stakeholders of the advantages of sexual risk avoidance approach in sex education, “Most people think it’s a ‘Just say no’ program – absolutely not,” she said. “Who thinks standing up in front of kids and saying ‘Just saying no’ is successful? We look at the totality of sexuality, and how it impacts relationships, and healthy and unhealthy relationships, dating violence, sexual assault, pregnancy, STDs, and the emotional consequences.”

To educate youth to look at sex and sexuality as a whole in an effort to avoid risky behavior, which can lead to not only unwanted pregnancies but sexually transmitted diseases, is one that is shared across the educational and political spectrum, from Ascend to Planned Parenthood of Michigan to the SHARE organization.

“STDs are up – but among sexually active teens. Students are actually having having less sex than they did 25 years ago. We’re making great strides,” said Ascend’s Mosack. “We’re trying to meet these sexually active teens and trying to educate these teens for more than just pregnancy prevention. We want to guide those students into risk-free status.”

Noting there is also an uptick in HIV, she said, “It’s very fortunate that we’ve made so many advances, but they think they can just take a pill and they’ll be OK. When AIDS was first presented, it was life-and-death. The commentary is that the threat level of it being life threatening has been diminished, so perhaps they feel less threatened. They then are more willing to participate in risky behavior.”

Mosack said that epidemiologists call it risk disinhibition – “’I use a condom almost every time, so I can be risky once in a while.’ Well, we know it only takes one time,” she said. “We’re all susceptible to it when we want to do what we want to do, and it’s part of the natural development for an adolescent – part of how they break away is to be risk takers; but some of them do it to greater degrees than others.”

As is required in Michigan, Planned Parenthood of Michigan teaches comprehensive abstinence-based sexuality training, said Ashley Coker, youth programs manager for Planned Parenthood of Michigan. She said they run a peer education program, where high school students go through about 40 hours of training before being tested to prove they understand medically-accurate information. The teens then help educate other teens, in schools or community presentations, and can serve as resources for their peers, Coker said, “providing that education, referrals to testing locations, and other services.”

“We are abstinence-based, and provide comprehensive sexuality education that includes abstinence. Then we educate young adults about the importance of STDs information and prevention, and we also encourage testing,” she said. 

“What we’re seeing as health educators is the number one contraceptive access is to condoms, but the female condom and dental dams are not sold in stores,” she said, both of which can help prevent STDs. “There are levels of difficulty to access, so even where teens are choosing to be responsible, there is difficulty in accessibility.” 

By law in Michigan, schools are not permitted to provide contraceptives of any kind on any site.

She said she believes another reason for the increase in STDs among young adults is that “youth in Michigan are often only receiving sexuality education one time in high school, for a limited time, and in Michigan, the law is we are abstinence-plus,” meaning the individual school district can choose what they can cover, as long as it includes abstinence information. “Some are abstinence only; some are abstinence-plus, meaning there is limited information about condoms and birth control; and some are comprehensive, and include information about consent, LBGTQ issues, etc.”

But the lack of repetitive education, which is effective in math, language, science, and every other subject, is lacking in this subject, with its potentially life-altering implications, Coker said. 

“There is a stigma regarding sexuality education and STDs,” she noted, about testing, education, and behaviors. “As an educator, I try to focus on behaviors, and not on labels.”

SHARE’s Van Sloten agrees. “We can provide the information, but we can’t control behavior,” she said. “We provide the information so they can make healthy choices and avoid risk.”

Beginning with middle schools, SHARE talks about the rise of poor choices in social media, the advent of sexting, and invasions of privacy. 

“Our young people are making poor choices. We talk to middle schoolers to think of themselves as more than just body parts, and to respect themselves,” she said. 

She said the rise in pornography, and its widespread accessibility on the internet, adds to students’ “disembodied” approach to sex and sexuality, along with a hook-up culture, “that you don’t need to have a relationship today to have sex. We tell them that it’s important to remember that feelings are natural, but acting on it is not.”

Coker agreed. “We are hearing more and more about the accessibility of pornography,” she said. “You no longer have to see it on cable, or get it in the mail. It’s right there in the palm of your hand. And pornography tends to portray unrealistic representations of what we believe young people see in sexual situations and that lack conversations about consent, and focuses on dominance, and lacks any focus on relationships.”

Both in middle school and high school, SHARE and Planned Parenthood discuss relationships and communication. “We don’t know what relationships are any more. A big part of the SHARE program is talking with other people, about how to share and communicate and how to trust someone worthy of your time,” Van Sloten said. “Relationships are not modeled successfully on TV. I tell kids people on TV sleep around, and you can’t – in real life there are consequences. STDs are part of that.”

She recalled the former U.S. Surgeon General C. Everett Koop’s warning in the 1980’s that when you slept with someone, you weren’t exposed to just your partner, but to anyone they’d been with in the past.

“That’s really it. I tell them, because everything today is instantaneous gratification, you can’t wipe things out like errors on a computer. Our bodies aren’t computers. Some (diseases) are for a lifetime,” Van Sloten said. “If they’re bacterial, yes, they can be cured. But only if you go to a doctor. Some are with you for a lifetime.”

All of the educators agree with the CDC and all medical professionals on the importance of being tested regularly for STDs if young adults are sexually active.

“There is so much focus on the act, and not on the connection – that’s the sad part, and that’s what they’re acting out, especially in this generation that’s all about texting,” Coker noted. “We have to help teach them to communicate, and in that way, negotiate their safety, and to care about themselves and to protect themselves and then to care about another person and respect the other person.

“We need to do a better job of modeling healthy relationships. This is really tough stuff, but it does take everyone to get involved – all the institutions, their peers, and all the adults in their lives, to change these statistics.” ­

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