Earlier this month, Poz magazine’s Benjamin Ryan drew attention to a concerning new study out of Northern California’s health system: Using data gathered from July 2012 through June 2015, researchers found that, among a cohort consisting mostly of same-sex–attracted men on the HIV-prevention regimen PrEP, “quarterly rates of rectal gonorrhea and urethral chlamydia increased steadily and about doubled after one year.” In other words, guys on the fantastically effective pill-a-day Truvada program were avoiding HIV infection—there were no new transmissions for regimen-adherent patients over the study period, in fact—but they seemed to be getting other sexually transmitted diseases relatively often. There are a few plausible explanations for the measured increase in this particular community, including the quarterly or at least semi-annual STD battery a PrEP prescription requires (more testing almost certainly means more diagnoses compared with men who infrequently or never get tested), and emerging evidence that many men, emboldened by PrEP, are engaging in more condomless sex. Either way, gay and bi men have reason to be alarmed.
This news came on the heels of a recent STD Surveillance Report from the Centers of Disease Control and Prevention which showed that the total combined cases of gonorrhea, chlamydia, and syphilis reported in the U.S. in 2015 reached record highs. Those most at risk were gay and bisexual men (regardless of their PrEP status), as well as the youth of America: Young adults aged 15 to 24 accounted for half the gonorrhea diagnoses and two-thirds of the chlamydia cases. Men who have sex with men (MSM) accounted for the majority of new gonorrhea and syphilis cases. And all this while strains of antibiotic-resistant gonorrhea were recently discovered to be on the rise among MSM.
As a journalist who covers sexual health and as a gay man who has sex, it seems to me that our community is on the cusp of a major STD epidemic. And although gonorrhea, chlamydia, and syphilis are certainly not the scourge HIV once was, I can’t help but feel a kind of old-fashioned, Larry Kramer–tinged guilt, like my community is to blame because of our more open relationship to sex. They say not to read comments sections online, but I couldn’t resist peeking at articles covering the CDC news. On a piece from USA Today, one person wrote: “Lot's of young whores out there today,” while another said, “looks like gays are determine[d] to do themselves harm.”
But is this accurate? Is “bad” sexual behavior among gays and other groups to blame for the trend? The answer is surely complicated, but if we want to better fight the rise in STD rates, we have to try to understand what’s driving it in the first place.
For the CDC’s part, the agency linked the national increase primarily to cuts to more than half of state and local STD screening programs’ budgets in recent years. This resulted in more than 20 health department clinic closures in one year, reducing access to testing and treatment for those who need it. It’s not hard to see how less testing and treatment would contribute to the spread of STDs across demographics.
But while the CDC’s explanation about budget cuts and clinic closures makes sense on a national scale, I have a sneaking suspicion that there had to be more to it than that for MSM. Within the gay and bi male community, I’ve recently noticed a lax attitude about contracting STDs on the part of some guys. The logic is something like: They’re treatable (for now), they’re not HIV, and they’re just kind of part of the sexual territory, so no biggie. Many gay men I know live in big cities that, for the moment, offer access to cheap or free testing and treatment—an unfortunately uncommon situation, as the CDC points out. To be honest, I personally don’t worry too much about STDs when I’m having sex. So perhaps we really are to blame for our own predicament?
“Yes, there are people who are less concerned about bacterial infections. We take antibiotics for a lot of reasons, and sexual health issues are one of them. I think there are some people who kind of anticipate, because of STI rates in certain communities, having an infection and they aren’t caught off guard when it happens,” Joshua O'Neal, the director of sexual health at San Francisco AIDS Foundation, told me over the phone.
O’Neal admitted, without qualms, that at the clinic they treat about 25 percent of the people on their PrEP program for STDs every three months—not necessarily because they have symptoms or tested positive for an STD, but because, in some instances, partners or a former lover may have informed them of a positive result.
This clinical insight jibes with the Northern California PrEP study. But O’Neal cautioned that the trend couldn’t only be attributed to behavior.
“It’s good to recognize that the people who are experiencing the most STI disparities aren’t just homos, but are young people between the ages of 15 to 24, are communities of color that also come from places where there’s not very good sex education,” he said. “We come from a very abstinence-only–based society. A lot of the numbers from the CDC are reflective of all the red states.”
And, when you dig down into the numbers, the CDC report validates exactly what O’Neal is saying. San Francisco has the highest number of LGBTQ residents per capita in the country; however, California ranked 17th in the country for chlamydia, 14th for gonorrhea, and third for syphilis. STDs are still a problem in California, but there are states with far worse situations. Louisiana, for example, ranked first for gonorrhea, with 221.1 people infected per 100,000, and first for syphilis with 15.0 people per 100,000. Alaska was ranked No. 1 for chlamydia, with 768.3 people infected per 100,000, followed by Louisiana and North Carolina.
I reached out to Patricia Kissinger to help contextualize these stats. She’s a professor with the Department of Epidemiology at the Tulane University School of Public Health and Tropical Medicine in Louisiana. “We’re in the Delta South, so a lot of the Southern states are very conservative, and one of the manifestations of that is they don’t agree with sex-ed,” she said. “They think that sex education should be done by the parents, and I think nobody would argue with that. But the problem is that the parents don’t do it—they don’t know how to do it, they don’t want to do it, so consequently the kids don’t get it.”
Kissinger explained how young people in the state don’t have the basic knowledge to protect themselves. They don’t know where to get a condom, how to use it, or even why they would need to use it. So maybe they aren’t just “young whores,” as that one commenter implied—they’re just undereducated.
Susan Jones, the HIV/STD program manager with the Alaska Department of Health and Social Services Section of Epidemiology, offered insight into the sex-ed question up north: “Alaska, traditionally, is very conservative state. … And has been a Republican state. The school districts in Alaska are individualized so each school district can decide how they’re going to address sexual health, and some are more conservative than others. There’s not a sexual health program that’s applied across the state in all school districts.”
In Alaska, HB 156 recently become law, which allows parents the right to direct the education of a child as it relates to sex education, human reproductive education, and human sexuality education, among other things. The bill doesn’t prevent the teaching of these subjects, but the curriculum, literature, or materials have to be approved by the district’s school board and available for parental review. I think it’s safe to assume that the resulting sex education wouldn’t be a liberal, sex-positive one.
In the Surveillance Report, the CDC highlights the necessity to mobilize, rebuild, and expand services to combat this epidemic and bolster prevention efforts. However, decisions about sex-ed curriculum are made by state and local school districts; the CDC doesn’t mandate specific sexual health education curricula. In some cases, they provide funding, tools, and technical assistance to state and local education agencies along with select NGOs for sex education activities, but the terms of how those are utilized vary state by state. Each state or local agency will decide what sort of programming they want to offer.
What’s more, with what little sex education that does occur in places like Louisiana, the law may preclude many of the most relevant things to teach. In that state, for example, instructors cannot use any sexually explicit materials depicting homosexual activity, nor can they hand out condoms. Which is somewhat irrelevant, since the students wouldn’t know how to properly use them—or why they might want to—anyway.
This lack of comprehensive sex education goes a long way to explaining why so many STDs aren't detected and go untreated. Some young people in Louisiana (or gay and bi people who used to be young in Louisiana) might not realize that you can get an STD from something like oral sex, whether giving or receiving. As a result, they won’t request a throat swab during testing, instead undergoing only a urine test, which says nothing about other potential sites of infection. Naturally, with a negative result added to the fact that many STDs can be asymptomatic, they'd conclude that everything is kosher, and transmission continues.
“Not everyone puts a penis in a vagina,” Jones points out, very matter-of-fact. “There are other places that become infected that haven’t been tested in the past and we’re finding that sex includes a lot of different body orifices, and all of those that have been exposed should be tested.” This means rectal swabs, too, but health providers may not test this area if they're unaware of their client’s sexuality or aren’t aware that even straight folks have anal sex. That, of course, would require one to be out and open about the type of sex they're having. And even then, in my experience, a nurse might not take a throat or rectal swab unless explicitly requested.
It’s a stark contrast to the sex-positive spaces found in a gay mecca like San Francisco, where people can talk openly about their sexual habits and get the appropriate tests and treatment that they need, shame free. “That’s what’s, again, unique about San Francisco: We’re so sex-positive, and we embrace it,” O'Neal told me, “where most places all over the United States don’t have that same approach.”
To be clear, this cultural explanation is not to downplay the CDC’s claim that, outside of unique cities like San Francisco and New York, the national increase is due to budget cuts and closures at state and local clinics. Such cuts result in reduced hours and staff at clinics that normally would provide treatment and prevention services. This could mean longer wait times, difficulty making appointments, and test results that take more time to get.
“You also have in Louisiana a heavy Baptist and Catholic tradition,” Kissinger told me. “They’re very anti-abortion so now they’re trying to close down any clinic that does any abortion.” It’s important to stress that while Planned Parenthood, which would be one such clinic, does perform abortions, that perfectly legitimate medical procedure accounts for only 3 percent of the work they do. Planned Parenthood also provides 4.2 million tests and treatments for STDs every year, which includes more than 650,000 HIV tests.
So when considering the STD uptick in the U.S. from a bird’s eye view, it isn’t really us urban gays, with our Grindr and PrEP and our sex-positivity/pleasure-first attitudes, that are driving the jump. Nor is it bored, rural youth purposefully being irresponsible with their sex lives. Not entirely, anyway. The real problem is the conservative legislators and parents in red states who are perpetuating this epidemic. And their fear and morality-based policy costs the health care system nearly $16 billion each year, according to the CDC, as STDs cause economic liabilities when undiagnosed and untreated.
As for the MSM community, it seems wise to continue to do what we do so well—which is also exactly what many conservative folks want us to stop doing: Talk about the sex we’re having, openly, so that we can eradicate stigma, educate one another, and normalize conversations and actions around sexual health. Each of these things encourage those in our community to get tested more frequently, and treated just as frequently without fear of being branded a “slut” for doing so. They can try to tell us that it’s behavior like this that drives STD rates up, but the evidence is quite clear: Sex positivity isn’t the problem. It’s part of the solution.