tag:theconversation.com,2011:/global/topics/sexually-transmitted-infection-1030/articlesSexually transmitted infection – The Conversation2024-02-25T14:16:50Ztag:theconversation.com,2011:article/2237162024-02-25T14:16:50Z2024-02-25T14:16:50ZFAQ: Why are syphilis cases on the rise in Canada?<figure><img src="https://images.theconversation.com/files/577183/original/file-20240221-24-guk2fk.jpg?ixlib=rb-1.1.0&rect=39%2C4%2C3253%2C2552&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Syphilis is a sexually transmitted infection (STI) caused by the Treponema pallidum bacterium.</span> <span class="attribution"><span class="source">(NIAID, cropped from original)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Canada has been experiencing an <a href="https://www.canada.ca/en/services/health/campaigns/syphilis.html">increasing number of syphilis diagnoses since 2016</a>. Numerous provinces have declared outbreaks in recent years, with the highest rates observed in the <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2023-49/issue-10-october-2023/infectious-congenital-syphilis-canada-2022.html">Northwest Territories, Saskatchewan and Manitoba</a>.</p>
<p>During Sexual Health Week this month, the Chief Public Health Officer of Canada, Dr. Theresa Tam, said the country has experienced an <a href="https://globalnews.ca/news/10294073/canada-syphilis-cases-phac/">“alarming increase” in syphilis cases</a>.</p>
<p>As an infectious disease physician, I know how important it is that Canadians have answers to common questions about syphilis, why it’s spreading and what the symptoms are.</p>
<p>Syphilis is an infection caused by the bacterium <em><a href="https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/treponema-pallidum-pathogen-safety-data-sheet.html">Treponema pallidum</a></em>, and is transmitted either through sexual exposure or from an infected pregnant woman into the developing fetus, resulting in congenital syphilis. </p>
<h2>Why is Canada seeing an increase in cases?</h2>
<p>In 2022, <a href="https://www.canada.ca/en/public-health/news/2024/02/statement-from-the-chief-public-health-officer-of-canada-on-syphilis.html">there were 13,953 reported syphilis cases, the highest seen in recent times, with rates increasing by 109 per cent compared to 2018</a>. While historically, gay, bisexual and other men who have sex with men remain at high risk of syphilis infections, recent years saw a surge in infections in heterosexual women, comprising of 35 per cent of all cases in 2022. This has led to a 600 per cent increase in the rates of congenital syphilis compared to previous years. </p>
<p>The reasons for this dramatic increase are not fully known, <a href="https://doi.org/10.14745%2Fccdr.v48i23a01">but may be attributed to several factors</a>: </p>
<ul>
<li><p>health-care disparity and lack of public health investment in surveillance and prevention as well as mistrust of the health-care system among some populations, such as Indigenous people, Black people and those who use substances, </p></li>
<li><p>introduction of highly effective HIV treatment as well as <a href="https://www.catie.ca/pre-exposure-prophylaxis-prep-0">pre-exposure prophylaxis (PrEP)</a> for HIV prevention may result in a decrease in condom use, </p></li>
<li><p>easier access to sex via online dating portals, and </p></li>
<li><p>rising rates of use of drugs while having sex, called party and play (PnP), coincides with increasing rates of syphilis infections.</p></li>
</ul>
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Read more:
<a href="https://theconversation.com/as-an-indigenous-doctor-i-see-the-legacy-of-residential-schools-and-ongoing-racism-in-todays-health-care-162048">As an Indigenous doctor, I see the legacy of residential schools and ongoing racism in today's health care</a>
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<h2>Who is most at risk?</h2>
<p>Since syphilis is typically a <a href="https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/risk-factors-clinical-manifestation.html">sexually transmitted infection</a>, certain <a href="https://doi.org/10.14745%2Fccdr.v48i23a01">high-risk practices</a> are associated with high risk of syphilis infection:</p>
<ul>
<li><p>Individuals who have unprotected sexual intercourse with multiple sex partners.</p></li>
<li><p>Commercial sex workers or those who exchange sex for drugs or money.</p></li>
<li><p>People living with HIV. Canadian studies have estimated the reported prevalence of syphilis to range <a href="https://www.canada.ca/en/public-health/services/emergency-preparedness-response/rapid-risk-assessments-public-health-professionals/risk-profile-infectious-syphilis-outbreaks-emergence-congenital-syphilis.html">between eight and 56 per cent</a> in this group.</p></li>
<li><p>Gay, bisexual and other men who have sex with men.</p></li>
<li><p>People who have been incarcerated and those who inject recreational substances.</p></li>
<li><p>Health Canada has also identified certain <a href="https://www.canada.ca/en/services/health/publications/diseases-conditions/syphilis-epidemiological-report.html#4">high-risk populations</a>, such as those experiencing health and social inequities, predominantly due to lack of accessible health care and screening.</p></li>
</ul>
<h2>What are the symptoms?</h2>
<p>The <a href="https://www.canada.ca/en/public-health/services/diseases/syphilis.html">symptoms of syphilis</a> can be divided into different stages, typically defined by when symptoms begin:</p>
<p><strong>1) Early Syphilis</strong> comprises primary and secondary syphilis, which typically occur within weeks to months following the exposure. This also includes early latent syphilis, an asymptomatic stage of the infection.</p>
<ul>
<li><p><strong>A)</strong> <strong>Primary syphilis</strong> is characterized by appearance of a painless sore at the site of infection, typically on the genitals or inside the mouth.</p></li>
<li><p><strong>B)</strong> <strong>Secondary syphilis</strong> is a systemic illness involving different organ systems. It presents with a diffuse body rash, fever, fatigue and sore throat. Wart-like skin lesions known as condyloma lata, alopecia (hair loss) and hepatitis may also occur in this stage.</p></li>
<li><p><strong>C)</strong> <strong>Early latent syphilis</strong> is an asymptomatic stage of the infection within a year of the initial exposure. It is diagnosed with positive blood tests in the absence of any symptoms. </p></li>
</ul>
<p><strong>2) Late Syphilis</strong> occurs in infected patients who do not receive treatment in the earlier stages and usually develops anywhere from one to 30 years after the initial infection. It is categorized into tertiary syphilis and late latent syphilis.</p>
<ul>
<li><p><strong>A)</strong> <strong>Tertiary syphilis</strong> involves chronic inflammation of the body, and may include skin, bones and other internal organs, specifically the cardiovascular system, brain and spinal cord. </p></li>
<li><p><strong>B)</strong> <strong>Late latent syphilis</strong>, much like early latent syphilis, is an asymptomatic stage of the infection, but in this case acquired more than a year previously. It is diagnosed based on positive blood tests. </p></li>
</ul>
<p><strong>3) Neurosyphilis</strong> can occur at any time during the course of infection, and may present in different forms, including meningitis, stroke, or vision or hearing loss. </p>
<h2>How is it transmitted?</h2>
<p>Syphilis is transmitted through direct exposure to an infectious lesion or sore on the skin (also called a chancre) <a href="https://www.canada.ca/en/public-health/services/laboratory-biosafety-biosecurity/pathogen-safety-data-sheets-risk-assessment/treponema-pallidum-pathogen-safety-data-sheet.html">during sexual intercourse or activity, including oral sex</a>. Additionally, <a href="http://www.bccdc.ca/health-info/diseases-conditions/syphilis">sharing sex toys</a> can also transmit infection between an infected individual and an uninfected one. </p>
<p>Congenital syphilis is acquired when the bacteria is passed through the placenta to a developing fetus, from an untreated pregnant person.</p>
<p>It should be noted that syphilis does not transmit through sharing utensils, toilet seats, bathtubs, swimming pools or clothes because the bacterium dies quickly outside the body. </p>
<h2>How is syphilis treated?</h2>
<p>Syphilis is an <a href="https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis.html#a1.4">easily treatable infection and duration of antibiotics is determined by the stage of the disease</a>. Early syphilis is treated with a one-time injection of the penicillin antibiotic into the buttock. Late syphilis is treated with three injections of penicillin, each a week apart, over three weeks. Neurosyphilis and syphilis involving the eyes or ears is typically treated with intravenous antibiotics for two weeks.</p>
<p>Alternative options for people who are either allergic to penicillins or cannot tolerate it include oral antibiotics, such as doxycycline or a once-daily intravenous antibiotic, called ceftriaxone. </p>
<h2>How can it be prevented?</h2>
<figure class="align-center ">
<img alt="Photo of two condoms in red packages" src="https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577185/original/file-20240221-20-6rivan.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Studies suggest that condoms reduce the risk of syphilis by around 90 per cent when used consistently.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>Syphilis is a preventable disease. It is important for high-risk and sexually active individuals to access counselling about safe sex practices and the importance of screening for sexually transmitted infections (STI screening). </p>
<p>Studies suggest that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4660551/">condoms reduce the risk of syphilis</a> by around 90 per cent when used consistently.</p>
<p>Several <a href="https://www.cdc.gov/std/treatment/doxycycline-as-pep-toe.htm">recently published studies</a> have reported promising outcomes in STI prevention (including gonorrhea, chlamydia and syphilis) with the use of an oral antibiotic — 200 milligrams of doxycycline — taken once within 24 to 72 hours after high-risk or condom-less sexual exposure. This is called post-exposure prophylaxis.</p>
<p>Additionally, easy and early access to health care and STI screening, as well as availability of post-exposure prophylaxis with the oral antibiotics, is important in preventing transmission to others. </p>
<p>With syphilis cases on the rise in Canada, it is important to know that the infection is treatable. Prevention is key not only to individual health but also to slowing its spread.</p><img src="https://counter.theconversation.com/content/223716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Huma Saeed does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>With the alarming rise in syphilis cases in recent years, it’s important to know what it is, how it’s spread and who is most at risk.Huma Saeed, Assistant Professor of Medicine, Division of Infectious Diseases, Schulich School of Medicine and Dentistry, Western UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1883282022-12-14T13:13:45Z2022-12-14T13:13:45ZMpox, AIDS and COVID-19 show the challenges of targeting public health messaging to specific groups without causing stigma<figure><img src="https://images.theconversation.com/files/500108/original/file-20221209-33805-9vw3eu.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C1020%2C708&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Fear-based public health messaging can both motivate and alienate at-risk groups.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSCrisis1987/8d02dadb8af04606bed1a5f9f6100ba1">AP Photo/Gillian Allen</a></span></figcaption></figure><p>During infectious disease outbreaks, clinicians and public health officials are tasked with providing accurate guidance for the public on how to stay safe and protect themselves and their loved ones. However, <a href="https://doi.org/10.3390%2Fijerph19148550">sensationalized media coverage</a> can distort how the public perceives new emerging infections, including where they come from and how they spread. This can foster <a href="https://doi.org/10.1016/j.lanepe.2022.100536">fear and stigma</a>, especially toward communities that are already mistrustful of the health care system.</p>
<p>The racial and sexual <a href="https://doi.org/10.3389/fpsyg.2021.648086">stigma surrounding monkeypox</a> is what spurred the World Health Organization to <a href="https://www.who.int/news/item/28-11-2022-who-recommends-new-name-for-monkeypox-disease">rename the disease to mpox</a> in November 2022. While this is a step in the right direction, I believe more work needs to be done to reduce the stigma surrounding infectious diseases like mpox.</p>
<p>I am an <a href="https://profiles.dom.pitt.edu/faculty_info.aspx/Ho5747">infectious disease researcher</a> who studies HIV, COVID-19 and mpox. During the COVID-19 pandemic, I was the lead investigator at the University of Pittsburgh for a <a href="https://www.coronaviruspreventionnetwork.org/compass-clinical-study">national survey</a> looking at how COVID-19 has affected different communities. Effective public health communication isn’t easy when conflicting messages may come from many sources, including family and friends, other community members or the internet. But there are ways that public health officials can make their own messaging more inclusive while mitigating stigma.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Posters promoting condom use reading " src="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500110/original/file-20221209-41828-ft8xxk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tailoring public health messages to target groups could improve their reach.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/posters-that-promote-healthy-sexual-behavior-hang-inside-news-photo/160899714">Chip Somodevilla/Getty Images</a></span>
</figcaption>
</figure>
<h2>Creating an inclusive message</h2>
<p>Inclusive public health messaging can motivate the public to make better decisions regarding their personal health and the health of others. This effort often involves engaging the communities most affected by an outbreak. Unfortunately, because these communities are heavily affected by the infection and tend to <a href="https://www.ama-assn.org/delivering-care/health-equity/impact-covid-19-minoritized-and-marginalized-communities">experience some form of inequity</a>, they are often blamed by society for spreading the disease.</p>
<p>COVID-19 drove an increase in hate crimes related to the pandemic against <a href="https://doi.org/10.1007/s12103-020-09545-1">Chinese and other Asian communities</a> in the United States. A <a href="https://healthpolicy.ucla.edu/newsroom/press-releases/pages/details.aspx">2022 UCLA survey</a> found that 8% of Asian American and Pacific Islander adults in California experienced a COVID-19 related hate incident.</p>
<p>Effective public health messaging can focus on the fact that while infections may first affect certain groups of people, they often <a href="https://doi.org/10.1098/rstb.2014.0111">spread to other groups</a> and eventually encompass entire communities. Infections are caused by bacteria, viruses and fungi. They don’t discriminate by race, gender or sexual orientation. Messages that focus on the pathogens, rather than the communities, may reduce stigma.</p>
<p><a href="https://www.cdc.gov/poxvirus/monkeypox/resources/reducing-stigma.html">Visually inclusive messages</a> are also likely to engage a greater portion of the community. Examples include making sure that the people represented in posters and flyers, images on TV and websites, and other informational material are from diverse backgrounds. This sends a more unified message that what affects an individual also affects the larger community.</p>
<h2>Avoiding blame and fear</h2>
<p>Many media outlets, especially on social media, use <a href="https://theconversation.com/does-scaring-people-work-when-it-comes-to-health-messaging-a-communication-researcher-explains-how-its-gone-wrong-during-the-covid-19-pandemic-174287">fear-based messaging</a> to report on infectious diseases. While this may reinforce certain protective behaviors, such as using condoms during sex, it may also increase stress and anxiety. Fear-based messages also <a href="http://dx.doi.org/10.1136/bmjgh-2019-001911">worsen stigma</a>, leading to increased discrimination against communities that are already vulnerable and mistrustful of health care. Ultimately, this leads people to avoid seeking health care and can worsen health outcomes.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/TRGZcNMR24o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Normalizing sexual health could help reduce stigma around sexually transmitted infections.</span></figcaption>
</figure>
<p>Public health officials have often used fear-based messaging in response to sexually transmitted infections, or STIs, like <a href="https://doi.org/10.1016%2FS2352-3018(21)00078-3">HIV</a>, <a href="http://dx.doi.org/10.1080/01292986.2017.1384030">chlamydia</a> and <a href="https://doi.org/10.1080/01292980600857831">gonorrhea</a>. Sex itself is <a href="https://magazine.jhsph.edu/2022/stigmas-toll-sexual-and-reproductive-health">highly stigmatized</a> by society. I have found that some of my patients would prefer to avoid getting tested and treated for an STI rather than deal with the <a href="https://www.verywellhealth.com/the-stigma-stds-have-in-society-3133101">shame of having an STI</a>.</p>
<p>Making sexual health and STI testing <a href="https://doi.org/10.1016/j.eclinm.2021.100764">routine and integral</a> parts of overall wellness and health is an important step to reduce the stigma around them. Similarly, messaging that normalizes the challenges faced by people at risk for certain infections could help avoid causing shame.</p>
<h2>Tailoring the message</h2>
<p>Infections affect different people differently. <a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html">COVID-19</a> might be a mildly stuffy nose for one person, and it could be months in an intensive care unit hooked up to a ventilator for another. Messages that <a href="https://www.hsph.harvard.edu/ecpe/the-importance-of-getting-the-message-right-in-your-risk-communication-strategy/">focus on the successes</a> of medical and public health interventions that resonate with communities are most likely to be successful.</p>
<p>Different groups have different exposure risks as well. Mpox heavily affected gay and bisexual men in 2022. One reason why was related to how the virus is transmitted. <a href="https://www.cdc.gov/poxvirus/monkeypox/if-sick/transmission.html#">Prior research</a> suggested that mpox was largely transmitted by close skin-to-skin contact, but <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/sex-men-not-skin-contact-fueling-monkeypox-new-research-suggests-rcna43484">emerging studies</a> raised the question of whether the 2022 outbreaks were being driven more by sexual transmission.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person passing poster with health information on mpox" src="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500109/original/file-20221209-40125-yviwsg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The 2022 mpox outbreaks predominantly affected gay and bisexual men.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/poster-on-commercial-street-in-provincetown-ma-on-the-issue-news-photo/1242177865">Jonathan Wiggs/The Boston Globe via Getty Images</a></span>
</figcaption>
</figure>
<p>There was <a href="https://www.npr.org/2022/07/26/1113713684/monkeypox-stigma-gay-community">controversy</a> as to whether public health messaging should highlight sexual encounters as a potential transmission route. This can risk further stigmatizing gay and bisexual men versus potentially overlooking these key at-risk populations. <a href="https://www.scientificamerican.com/article/monkeypox-is-a-sexually-transmitted-infection-and-knowing-that-can-help-protect-people">Some advocates argued</a> that promoting the message that mpox was primarily transmitted by close contact would prevent resources and interventions from reaching the groups of people most affected by the disease.</p>
<p>One size does not always fit all when it comes to public health messaging. Multiple messages may be necessary for different groups of people based on their risk of infection or severe disease. An August 2022 Centers for Disease Control and Infection survey found that <a href="http://dx.doi.org/10.15585/mmwr.mm7135e1">50% of gay and bisexual men</a> reduced their sexual encounters in response to the mpox outbreak. Since late summer, <a href="https://www.npr.org/sections/health-shots/2022/08/26/1119659681/early-signs-suggest-monkeypox-may-be-slowing-in-the-u-s">mpox rates have been dropping</a> rapidly, and many experts think that both behavior change and vaccination may have contributed to the falling rates. Studies like these further support the importance of directly engaging with communities to encourage healthy behavior change.</p>
<h2>Trusted messengers</h2>
<p>Mistrust is also a barrier to effective messaging. Some communities may be mistrustful of medical and health care systems because of prior histories of exploitation, such as the <a href="https://www.mcgill.ca/oss/article/history/40-years-human-experimentation-america-tuskegee-study">Tuskegee study</a>, where researchers prevented Black participants from receiving syphilis treatment for decades in the mid-20th century, and ongoing fear of mistreatment.</p>
<p>Identifying trusted community champions and health care providers – especially ones who belong to that community – to deliver a public health message may increase its acceptance. One <a href="https://doi.org/10.1257/aer.20181446">2019 study</a>, for example, found that Black men were more likely to accept vaccines, medical advice and engage in health care services if they had a Black health care provider.</p>
<p>Effectively delivering public health messaging is a complicated and challenging process. But talking to and listening to the communities most affected by an outbreak can make a difference.</p><img src="https://counter.theconversation.com/content/188328/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ken Ho does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prejudice and stigma can discourage the communities most affected by infectious diseases from seeking care. Inclusive public health messaging can prevent misinformation and guide the most vulnerable.Ken Ho, Assistant Professor of Infectious Diseases, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879092022-10-05T12:20:12Z2022-10-05T12:20:12ZGonorrhea became more drug resistant while attention was on COVID-19 – a molecular biologist explains the sexually transmitted superbug<figure><img src="https://images.theconversation.com/files/484662/original/file-20220914-18-3dakt1.jpg?ixlib=rb-1.1.0&rect=21%2C32%2C7156%2C3977&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The _Neisseria gonorrhoeae_ bacterium causes gonorrhea by infecting mucous membranes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/bacterium-neisseria-gonorrhoeae-gonorrhea-royalty-free-image/1128533488?adppopup=true">Design Cells/iStock Getty Images Plus via Getty Images</a></span></figcaption></figure><p>COVID-19 has rightfully dominated infectious disease news since 2020. However, that doesn’t mean other infectious diseases took a break. In fact, U.S. rates of <a href="https://www.cdc.gov/std/statistics/2020/tables/1.htm">infection by gonorrhea have risen</a> during the pandemic.</p>
<p>Unlike COVID-19, which is a new virus, gonorrhea is an ancient disease. The first known reports of gonorrhea date from <a href="https://doi.org/10.1001/archdermatol.2011.2716">China in 2600 BC</a>, and the disease has plagued humans ever since. Gonorrhea has long been one of the most commonly reported <a href="https://www.cdc.gov/std/statistics/2020/tables/1.htm">bacterial infections in the U.S.</a>. It is caused by the bacterium <em>Neisseria gonorrhoeae</em>, which can infect mucous membranes in the genitals, rectum, throat and eyes. </p>
<p>Gonorrhea is typically transmitted by sexual contact. It is sometimes <a href="https://www.emedicinehealth.com/why_is_gonorrhea_called_the_clap/article_em.htm">referred to as “the clap</a>.” </p>
<p>Prior to the pandemic, there were around <a href="https://www.cdc.gov/std/gonorrhea/arg/public-health-threat/public-health-threat-text-only.htm">1.6 million new gonorrhea infections</a> each year. Over 50% of those cases involved strains of gonorrhea that had <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">become unresponsive to treatment</a> with at least one antibiotic. </p>
<p>In 2020, gonorrhea infections initially <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">went down 30%</a>, most likely due to pandemic lockdowns and social distancing. However, by the end of 2020 – the last year for which data from the Centers for Disease Control and Prevention is available – <a href="https://www.cdc.gov/std/gonorrhea/stats.htm">reported infections were up 10% from 2019</a>. </p>
<p>It is unclear why infections went up even though some social distancing measures were still in place. But the CDC notes that reduced access to health care may have led to longer infections and more opportunity to spread the disease, and sexual activity may have increased when <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">initial shelter-in-place orders were lifted</a>.</p>
<p>As <a href="https://science.psu.edu/bmb/people/kck11">a molecular biologist</a>, I have been <a href="https://scholar.google.com/citations?user=rkmd4gQAAAAJ&hl=en">studying bacteria</a> and working to develop new antibiotics to treat drug-resistant infections for 20 years. Over that time, I’ve seen the problem of antibiotic resistance take on new urgency. </p>
<p>Gonorrhea, in particular, is a major public health concern, but there are concrete steps that people can take to prevent it from getting worse, and new antibiotics and vaccines may improve care in the future. </p>
<h2>How to recognize gonorrhea</h2>
<p>Around <a href="https://doi.org/10.1016/S0091-7435(02)00058-0">half of gonorrhea infections are asymptomatic</a> and can only be detected through screening. Infected people without symptoms can unknowingly spread gonorrhea to others.</p>
<p>Typical early <a href="https://www.mayoclinic.org/diseases-conditions/gonorrhea/symptoms-causes/syc-20351774">signs of symptomatic gonorrhea</a> include a painful or burning sensation when peeing, vaginal or penal discharge, or anal itching, bleeding or discharge. Left untreated, gonorrhea can cause <a href="https://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea.htm">blindness and infertility</a>. Antibiotic treatment can cure most cases of gonorrhea as long as the infection is susceptible to <a href="https://www.cdc.gov/std/gonorrhea/treatment.htm">at least one antibiotic</a>.</p>
<p>There is currently only one recommended treatment for gonorrhea in the U.S. – an antibiotic called ceftriaxone – because the bacteria have become resistant to other antibiotics that were <a href="https://www.cdc.gov/std/gonorrhea/treatment.htm">formerly effective against it</a>. Seven different families of antibiotics have been used to treat gonorrhea in the past, but many strains are now resistant to <a href="https://www.who.int/news-room/fact-sheets/detail/multi-drug-resistant-gonorrhoea">one or more of these drugs</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iFwlnljV2Go?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The CDC tracks the emergence and spread of drug-resistant gonorrhea strains.</span></figcaption>
</figure>
<h2>Why gonorrhea is on the rise</h2>
<p>A few factors have contributed to the increase in infections during the COVID-19 pandemic.</p>
<p>Early in the pandemic, most U.S. labs capable of testing for gonorrhea switched to testing for COVID-19. These labs have also been contending with the same <a href="https://www.usnews.com/news/health-news/articles/2022-07-28/staff-shortages-choking-u-s-health-care-system">shortages of staff</a> and <a href="https://www.aamc.org/news-insights/shortages-syringes-dye-diagnostic-exams-how-world-events-are-straining-everyday-health-care-supply">supplies that affect</a> <a href="https://www.cdc.gov/std/statistics/2020/impact.htm">medical facilities across the country</a>.</p>
<p>Many people have <a href="https://doi.org/10.1371/journal.pone.0272609">avoided clinics and hospitals</a> during the pandemic, which has decreased opportunities to identify and treat gonorrhea infections before they spread. In fact, because of decreased screening over the past two and a half years, health care experts don’t know exactly how much antibiotic-resistant gonorrhea has spread.</p>
<p>Also, early in the pandemic, many doctors <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">prescribed antibiotics to COVID-19 patients</a> even though antibiotics do not work on viruses like SARS-CoV-2, the virus that causes COVID-19. Improper <a href="https://www.cdc.gov/antibiotic-use/index.html">use of antibiotics</a> can contribute to greater drug resistance, so it is reasonable to suspect that this has happened with gonorrhea.</p>
<h2>Overuse of antibiotics</h2>
<p>Even prior to the pandemic, resistance to antibiotic treatment for bacterial infections was a growing problem. In the U.S., antibiotic-resistant gonorrhea infections <a href="https://www.cdc.gov/drugresistance/pdf/covid19-impact-report-508.pdf">increased by over 70%</a> from 2017-2019.</p>
<p><em>Neisseria gonorrhoeae</em> is a specialist at picking up new genes from other pathogens and from <a href="https://doi.org/10.1038/nrmicro.2017.169">“commensal,” or helpful, bacteria</a>. These helpful bacteria can also become antibiotic-resistant, providing more opportunities for the gonorrhea bacterium to acquire resistant genes.</p>
<p>Strains resistant to ceftriaxone have been observed in other countries, including <a href="https://doi.org/10.1128/AAC.00325-11">Japan</a>, <a href="https://doi.org/10.1038/s41598-021-00675-y">Thailand,</a> <a href="https://doi.org/10.1016/S1473-3099(20)30055-4">Australia and the U.K.</a>, raising the possibility that some gonorrhea infections may soon be completely untreatable. </p>
<h2>Steps toward prevention</h2>
<p>Currently, changes in behavior are among the best ways to limit overall gonorrhea infections – particularly <a href="https://www.who.int/news/item/07-07-2017-antibiotic-resistant-gonorrhoea-on-the-rise-new-drugs-needed">safer sexual behavior and condom use.</a></p>
<p>However, additional efforts are needed to delay or prevent an era of untreatable gonorrhea. </p>
<p>Scientists can create new antibiotics that are effective against resistant strains; however, decreased investment in this research and development over the past 30 years <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358500/">has slowed the introduction</a> of <a href="https://www.idsociety.org/globalassets/idsa/policy--advocacy/current_topics_and_issues/antimicrobial_resistance/10x20/statements/070104-as-antibiotic-discovery-stagnates-a-public-health-crisis-brews.pdf">new antibiotics to a trickle</a>. No new drugs to treat gonorrhea have been introduced since 2019, although <a href="https://doi.org/10.1128/aac.01991-21">two are in the final stage</a> of clinical trials.</p>
<p>Vaccination against gonorrhea isn’t possible presently, but it could be in the future. Vaccines effective against the meningitis bacterium, a close relative of gonorrhea, can sometimes also provide <a href="https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies">protection against gonorrhea</a>. This suggests that a gonorrhea vaccine should be achievable. </p>
<p>The World Health Organization has begun an initiative to <a href="https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/strategies/global-health-sector-strategies">reduce gonorrhea worldwide by 90%</a> before 2030. This initiative aims to promote safe sexual practices, increase access to high-quality health care for sexually transmitted diseases and expand testing so that asymptomatic infections can be treated before they spread. The initiative is also advocating for increased research into vaccines and new antibiotics to treat gonorrhea.</p>
<p>Setbacks in fighting drug-resistant gonorrhea during the COVID-19 pandemic make these actions even more urgent.</p><img src="https://counter.theconversation.com/content/187909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kenneth Keiler receives funding from NIH.</span></em></p>The US currently has only one antibiotic available to treat gonorrhea – and it’s becoming less effective.Kenneth Keiler, Professor of Biochemistry and Molecular Biology, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1886282022-08-16T20:39:37Z2022-08-16T20:39:37ZTreating monkeypox like an STI may help control the outbreak, but stigma is a danger<figure><img src="https://images.theconversation.com/files/479474/original/file-20220816-9810-ms19br.jpg?ixlib=rb-1.1.0&rect=0%2C77%2C1789%2C1319&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Monkeypox is transmitted mainly through direct contact with skin lesions, but the current outbreak is following patterns similar to STIs.</span> <span class="attribution"><span class="source">(NIAID, cropped from original)</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The recent monkeypox global outbreak, now declared by the World Health Organization as a <a href="https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern">Public Health Emergency of International Concern</a> (PHEIC), is sadly yet another reason for society to stigmatize and discriminate against the LGTBQ2SA+ community. This is in part because it has been suggested that monkeypox is a sexually transmitted infection (STI).</p>
<p><a href="https://www.who.int/news-room/fact-sheets/detail/monkeypox">Monkeypox started as a zoonosis</a> (an infection transmitted by contact with animals). However, this close relative of the variola virus (which causes smallpox) can also be transmitted from human to human, mainly through direct contact with the skin lesions. </p>
<p>Although transmission through semen and vaginal secretions has yet to be proven, it can be transmitted during sexual intercourse because of the obvious close contact it entails. </p>
<p>Cases have been identified for decades mainly in West African countries, but it was only recently when cases appeared in Europe and America that it caught the international attention it deserved. Cases continue to rise in many countries, to the point of prompting the WHO to declare it a PHEIC. </p>
<p><a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2207323">One excellent study</a> put together a series of 500 patients distributed across 16 countries. The researchers analyzed patients’ demographics as well as their clinical characteristics. They found that 98 per cent of the cases were men who prefer to have sex with men (MSM). Of note, 41 per cent of the cases were people living with HIV (PLWH). </p>
<h2>Characteristics of lesions</h2>
<p>Another finding was the characteristics of the lesions. Monkeypox used to present with skin lesions mainly on the face, trunk, arms and legs, but most of the reported cases during this global outbreak have had a different presentation. Many cases have lesions in the perineal region (73 per cent) or genitals or even around the mouth. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man in a black T-shirt is pointing at a large screen showing a series of images of skin lesions." src="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=337&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=337&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=337&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479465/original/file-20220816-10908-w9vs5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An epidemiologist conducts monkeypox disease training to health investigators at the Salt Lake County Health Department on July 29, 2022, in Salt Lake City.</span>
<span class="attribution"><span class="source">(AP Photo/Rick Bowmer)</span></span>
</figcaption>
</figure>
<p>This could be consistent with sexual transmission as the lesions are presenting at the site of infection, a clinical course also described in <a href="https://doi.org/10.1016/S0140-6736(22)01436-2">this paper from Spain</a>. Additionally, 30 per cent of the patients also have another more common STI such as gonorrhea or syphilis, a pattern frequently found in many STIs. Managing a patient with an STI always implies ruling out other STIs. </p>
<p>Grouping diseases by their mode of transmission is helpful for doctors because it allows us to make mental lists of probable causes when confronted with a case. We call this differential diagnosis. </p>
<p>When a patient presents with a genital lesion, a health-care provider will establish a list of possible diagnoses based on the characteristics of the lesion, the accompanying symptoms and the local epidemiology. This makes it possible to treat empirically (before we can confirm the diagnosis) for the most probable cause. </p>
<h2>What is an STI?</h2>
<p>Any disease passed from one person to another through bodily fluids during a sexual encounter is <a href="https://www.who.int/health-topics/sexually-transmitted-infections#tab=tab_1">considered an STI</a>. However there are diseases that occur more frequently than others and as such are grouped in this category, such as chlamydia and gonorrhea. </p>
<p>Other diseases may be transmitted through genital secretions but are not considered an STI by the medical community. For example, Ebola has been shown to be <a href="https://doi.org/10.1371/journal.pmed.1003273">transmitted through genital secretions</a>, however it is not considered within the group of the more frequent STIs because it is not its main mode of transmission. </p>
<figure class="align-center ">
<img alt="A man in a plaid shirt getting an injection from a woman in a blue dress and face mask, both sitting in folding chairs, seen from behind" src="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479471/original/file-20220816-22-9qskhm.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A man receives a monkeypox vaccine at an outdoor walk-in clinic in Montréal in July 2022.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>The mode of presentation of monkeypox during this global outbreak has <a href="https://doi.org/10.1016/S0140-6736(22)01497-0">prompted the medical community</a> to consider monkeypox diagnosis, along with other STIs, in any person who has had a recent unprotected sexual contact, and presents with a painful skin lesion in the genitals, perianal region or mouth.</p>
<p>Considering monkeypox as an STI seems logical in order to face the current outbreak, but the <a href="https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-2-february-1-2018/article-5-stigma-sexually-transmitted-infections.html">stigma and discrimination</a> this could cause is a major problem. An infection acquired through sex is still something that causes guilt and fear of rejection by society. STIs are still viewed by many as a <a href="https://slate.com/technology/2019/12/genital-herpes-stigma-history-explained.html">punishment for certain behaviours</a>. </p>
<p>Additionally, classifying monkeypox as an STI may create a false sense of security for people who may think they’re not at risk. Both stigma and a low perception of risk can hinder efforts for early identification of cases, rapid isolation and limitation of the outbreak. Worst of all, stigma related to this outbreak would perpetuate harms to the LGTBQ2SA+ community.</p>
<p>Monkeypox is behaving like an STI during this global outbreak, so including this diagnosis as part of sexual health management may be beneficial to stop transmission. However, bigger efforts addressing stigma and discrimination are necessary.</p><img src="https://counter.theconversation.com/content/188628/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Santiago Perez Patrigeon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Monkeypox is not considered an STI but is spreading among sexual partners. Adding sexual health strategies to the public health response is helpful, but there is a danger of stigmatizing MPXV.Santiago Perez Patrigeon, Assistant professor, Division of Infectious Diseases, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1821142022-07-13T12:30:09Z2022-07-13T12:30:09ZManuscripts and art support archaeological evidence that syphilis was in Europe long before explorers could have brought it home from the Americas<figure><img src="https://images.theconversation.com/files/473438/original/file-20220711-26-m03ndy.jpg?ixlib=rb-1.1.0&rect=233%2C137%2C2193%2C1714&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Does a painting from 1400 depict one of Jesus' torturers as suffering from 'saddle nose,' a common effect of syphilis?</span> <span class="attribution"><a class="source" href="https://www.clevelandart.org/art/1945.115">Detail of an Austrian painting c. 1400 of the Passion of Christ, The Cleveland Museum of Art</a></span></figcaption></figure><p>That the arrival of Europeans in the New World in 1492 led to a massive shift in the ecological landscape has been widely accepted <a href="https://www.smithsonianmag.com/history/alfred-w-crosby-on-the-columbian-exchange-98116477/">for the past 50 years</a>. Suddenly a trans-Atlantic exchange – maize for wheat, tomatoes for apples, tobacco for horses – meant that plants and animals were moving between continents for the first time.</p>
<p>It was the same for pathogens, according to historian Alfred W. Crosby and his influential book “<a href="https://www.worldcat.org/title/columbian-exchange-biological-and-cultural-consequences-of-1492/oclc/930378865&referer=brief_results">The Columbian Exchange</a>.” Diseases like smallpox and measles, brought to the Western Hemisphere by the invaders, soon killed <a href="https://theconversation.com/how-smallpox-devastated-the-aztecs-and-helped-spain-conquer-an-american-civilization-500-years-ago-111579">almost the entire Indigenous population</a>. In return, Europeans fell prey to <a href="https://www.cdc.gov/std/syphilis/stdfact-syphilis.htm">syphilis, a venereal disease</a> they picked up from the native people. Crosby’s idea about the exchange of diseases was an interesting one and it made for a good story, suggesting that with the arrival of syphilis in Europe justice of a sort had been done.</p>
<p>The only problem is that this syphilis scenario is wrong, according to <a href="https://doi.org/10.1002/ajpa.23988">ongoing research by paleopathologists</a>, scientists who study skeletal remains for evidence of disease. After decades of painstaking work, they have concluded that the syphilis-causing spirochete bacterium <em>Treponema pallidum</em> already existed in the Old World long before Columbus boarded his ship and sailed to Hispaniola.</p>
<p>As a <a href="https://scholar.google.com/citations?user=K6x0M5sAAAAJ&hl=en&oi=ao">women’s historian</a> who has studied documents and artworks for <a href="https://muse.jhu.edu/article/842358">evidence of syphilis in the medieval period</a>, I believe the paleopathologists are right. Like skeletal remains, paintings show life as it was. Even manuscripts, although more open to interpretation, can reveal the truth once readers open their minds to new possibilities. Here’s a sample of the evidence that <a href="https://www.arc-humanities.org/9781802700480/medieval-syphilis-and-treponemal-disease/">Europeans suffered from syphilis long before they reached the Americas</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="microscopic image of long white worm-like shapes" src="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=395&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=395&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=395&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=496&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=496&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473689/original/file-20220712-13-wzc26o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=496&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"><em>Treponema pallidum</em> is a spiral-shaped bacterium that causes the disease syphilis.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/treponema-pallidum-dark-field-preparation-syphilis-image-news-photo/509391914">CDC/Susan Lindsley/Smith Collection/Gado via Getty Images</a></span>
</figcaption>
</figure>
<h2>Evidence from bones and teeth in the Old World</h2>
<p>In a cemetery in West Sussex, U.K., archaeologists uncovered the <a href="https://doi.org/10.1002/ajpa.22630">skeleton of a young man</a> with extensive damage to his skull, clavicles, arms and legs – a combination typical of syphilis. He died in the sixth century. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="skull with hole and areas where bone looks rotted away" src="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=604&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=604&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=604&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=759&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=759&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473456/original/file-20220711-18-t1llj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=759&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">View of a human skull damaged by late-stage syphilis, the kind of evidence paleopathologists can look for.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Skull_damage_from_neurosyphilis.jpg">Canley/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In St. Polten, Austria, a medieval cemetery holds the <a href="https://doi.org/10.1127/anthranz/2015/0504">remains of a child</a> age 6 with deformed teeth consistent with a diagnosis of treponematosis, perhaps a case of <a href="https://www.cdc.gov/std/syphilis/stdfact-congenital-syphilis.htm">congenital syphilis</a>, when the <em>Treponema pallidum</em> bacteria are passed from mother to child during pregnancy or birth.</p>
<p>In Anatolia in western Turkey, the <a href="https://doi.org/10.1002/oa.802">skeleton of a teenager</a> revealed not only the same deformed incisors as in St. Polten, but also damage to the entire skeleton below the head. Involvement of both teeth and bones in the same specimen, and especially the large number of bones affected in this case, points to syphilis. The victim died in the 13th century – a couple hundred years before Columbus set sail. </p>
<p>And so it goes. While the absolute number of cases is not large, <a href="https://doi.org/10.1002/ajpa.22630">they keep turning up</a>. Some of the evidence appears in the remains of people who <a href="https://www.worldcat.org/title/origine-de-la-syphilis-en-europe-avant-ou-apres-1493-actes-du-colloque-international-de-toulon-25-28-novembre-1993/oclc/884173338&referer=brief_results">lived more than 2,000 years ago</a>.</p>
<p>There is an outstanding issue, however. Damaged bones and teeth seem to hold proof of pre-Columbian syphilis, but there is a possibility that they point to another form of the disease instead. <em>Treponema pallidum</em> appears in several strains. The subspecies that causes syphilis is the deadliest. But two other subspecies of the bacteria cause less serious, if still painful and unsightly, diseases called <a href="https://rarediseases.org/rare-diseases/bejel/">bejel</a> (also known as endemic syphilis) and <a href="https://www.who.int/news-room/fact-sheets/detail/yaws">yaws</a> that are <a href="https://www.merckmanuals.com/home/infections/bacterial-infections-spirochetes/bejel-yaws-and-pinta">not usually transmitted sexually</a>. Nowadays all three can be treated with antibiotics.</p>
<p>How then, to distinguish between the three subspecies and prove that the venereal form had existed in Europe all along?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="detail of medieval painting of Jesus in crown of thorns amid crowd" src="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=461&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=461&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=461&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=579&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=579&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473707/original/file-20220712-13-it6ehd.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=579&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In an early 15th-century painting, a discerning historian’s eye sees two soldiers (one in yellow, one behind red plume) with facial features indicative of advanced syphilis leading Christ to his crucifixion.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Master_of_the_Karlsruhe_Passion_-_Disrobing_of_Christ.jpeg">The Disrobing of Christ from the Karlsruhe Passion (detail), c.1440. Staatliche Kunsthalle Karlsruhe, Strasbourg</a></span>
</figcaption>
</figure>
<h2>Writers and artists recorded other evidence</h2>
<p>Documentary and artistic evidence can help settle the issue. Of all the pathogens known to humanity, only treponemes produce <a href="https://doi.org/10.1001/archderm.1970.04000070080012">such widely divergent outcomes based on climate and culture</a>, an important clue for finding evidence in manuscripts.</p>
<p>This fact explains my theory that medieval elites suffered more severely from treponematosis than peasants. Their wealthy lifestyle would have protected them from childhood infections their social inferiors picked up in their crowded and unsanitary households. But those childhood sicknesses would have had the benefit of triggering some future immunity in the peasantry.</p>
<p>If members of the elite reached sexual maturity without having had milder infections while growing up, they would be highly susceptible to contracting the disease for the first time during intercourse. A sore on the genitalia contains a massive dose of infectious bacteria compared with the small doses found on the shared clothing or bedding of the peasantry. Peasants who suffered a recurrence of the disease as adults could likely fend it off successfully because of their prior immunity. I contend this was not true for elites who then suffered more devastating illnesses.</p>
<p>In addition to dying young themselves, infected elites risked giving their children congenital syphilis, which often proved fatal to the next generation. Elites and their children died in such high numbers that some noble families <a href="https://global.oup.com/academic/product/the-crisis-of-the-aristocracy-1558-to-1641-9780198213147">had trouble maintaining their bloodlines</a>, a point noted long ago without making a potential connection to syphilis.</p>
<p>One royal who <a href="https://muse.jhu.edu/article/842358">I believe almost certainly died of syphilis</a> was king Edward IV of England (1442-83). One of his councilors wrote that he died of an illness difficult to cure even in a person of lesser status, a cryptic comment not previously understood by historians. But his statement perfectly fits the difference between venereal and endemic syphilis, evidence that suggests both diseases existed in 15th-century England. The <a href="https://yalebooks.yale.edu/book/9780300073720/edward-iv/">king’s symptoms and reputation for sexual promiscuity</a> help confirm my diagnosis.</p>
<p>Evidence for the presence of syphilis in the Old World also comes from art.</p>
<p>Doctors know that <a href="https://doi.org/10.1001/archderm.1970.04000070080012">syphilis can result in</a> “<a href="https://phil.cdc.gov/Details.aspx?pid=17626">saddle nose</a>,” in which spirochetes invade a patient’s nose and cause it to collapse in a distinctive way. Medieval artists from as early as the 12th century depicted this deformity in their work.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side view of man with a collapsed nose, paired with medieval painting of Jesus and a persecutor" src="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473690/original/file-20220712-9214-kddbhp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In a medieval painting, one of Christ’s tormentors has facial features reminiscent of a syphilis patient’s saddle nose.</span>
<span class="attribution"><a class="source" href="https://www.bl.uk/manuscripts/Viewer.aspx?ref=yates_thompson_ms_13_fs001r">L: British Journal of Plastic Surgery, Vol. 10, McLaren + Penney, The reconstruction of the syphilitic saddle nose: A review of seven cases, Pages 236-252, Copyright 1957–1958. R: The Taymouth Hours, England, mid-14th century. British Library, MS Yates Thompson 13, fol. 120v.</a></span>
</figcaption>
</figure>
<p>I believe they intended to show venereal and not endemic disease because they use saddle nose in depictions of sinful figures, including the men who tortured Christ or killed babies on the orders of King Herod.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Front view of man with a collapsed nose, paired with drawing of a monster with a snub-nosed face on a pair of legs" src="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/473692/original/file-20220712-31783-6pl4a3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A gryllus displaying the saddle nose deformity in a drawing from the early 1300s.</span>
<span class="attribution"><a class="source" href="https://www.bl.uk/manuscripts/Viewer.aspx?ref=stowe_ms_17_fs001r">L: British Journal of Plastic Surgery, Vol. 10, McLaren + Penney, The reconstruction of the syphilitic saddle nose: A review of seven cases, Pages 236-252, Copyright 1957–1958. R: The Maastricht Hours, Liège, early 14th century. British Library, MS Stowe 17, fol. 151r.</a></span>
</figcaption>
</figure>
<p>Even the silly gryllus, a medieval monster with a face and legs but no body, was a symbol of human depravity.</p>
<p>Examples abound. Historians have ignored good evidence – as plain as the nose on your face, so to speak – because they believed in the Columbian exchange. Regarding syphilis, however, that intellectual framework now appears outdated.</p><img src="https://counter.theconversation.com/content/182114/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marylynn Salmon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The idea that Europeans brought new diseases to the Americas and returned home with others has been widely accepted. But evidence is mounting that for syphilis this scenario is wrong.Marylynn Salmon, Research Associate in History, Smith CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1761322022-02-10T20:24:26Z2022-02-10T20:24:26ZChildhood adversity is a ‘cause of causes’ of adult illnesses and mental health problems<figure><img src="https://images.theconversation.com/files/443792/original/file-20220201-22-127qj18.png?ixlib=rb-1.1.0&rect=16%2C663%2C4497%2C2948&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One child in three is physically or sexually abused or witnesses violence between adults in their home. Other adversities including emotional neglect, living in an unsafe neighbourhood or experiencing prejudice and bullying are even more common.</span> <span class="attribution"><span class="source">(iStock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/childhood-adversity-is-a--cause-of-causes--of-adult-illnesses-and-mental-health-problems" width="100%" height="400"></iframe>
<p>Every day we are exposed to things like pollution and ultraviolet light which increase our risk of illness. Many people take on additional risks — due to tobacco smoke, fast food or alcohol, for example. </p>
<p>But there is a less-recogized exposure that is even more common than smoking and increases the risk of <a href="https://doi.org/10.1161/cir.0000000000000536">heart disease, diabetes</a>, <a href="https://doi.org/10.1002/cncr.24372">cancer</a>, <a href="https://doi.org/10.1016/s0749-3797(98)00017-8">chronic lung diseases</a>, <a href="https://dx.doi.org/10.2105%2FAJPH.2007.131599">sexually transmitted infections</a>, <a href="https://doi.org/10.1001/jama.2009.1091">chronic pain</a>, <a href="https://doi.org/10.1503/cmaj.131792">mental illness</a> and <a href="https://doi.org/10.1016/j.amepre.2009.06.021">reduces one’s life by as much as 20 years</a>. </p>
<p>This public health hazard that hides in plain sight is childhood adversity: experiences like physical abuse, sexual abuse and neglect.</p>
<h2>Childhood adversity is common</h2>
<p>In Canada, <a href="https://doi.org/10.1503/cmaj.131792">one child in three is physically or sexually abused or witnesses violence between adults in their home</a>. Other adversities such as <a href="https://doi.org/10.1016/j.amepre.2015.02.001">emotional neglect, living in an unsafe neighbourhood or experiencing prejudice and bullying</a> are even more common. Studies in the United States show about <a href="https://doi.org/10.1016/j.amepre.2014.09.006">60 per cent of children and teenagers have these adverse childhood experiences</a>, or ACEs. The more severe the exposure, the greater the health risk. </p>
<p>The reason that ACEs contribute to so many diseases is that they are associated with many things that trigger other causes of disease. Think of ACEs as a “cause of causes.”</p>
<h2>Health risk behaviours and physiological changes</h2>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of two people standing at a starting line. One lane is clear while the other has a pitfall." src="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445491/original/file-20220209-1970-18lmi5a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adverse childhood events may contribute to cascading health risks over a lifetime.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>As kids who have had adverse experiences grow up, they are more likely to <a href="https://dx.doi.org/10.1016%2Fj.jadohealth.2007.08.029">smoke</a>, to <a href="https://doi.org/10.1111/acer.12053">drink excessively</a> and to <a href="https://dx.doi.org/10.1016%2Fj.jaac.2016.05.010">use nonprescription drugs</a>. They are more likely to <a href="https://doi.org/10.1016/j.chiabu.2016.11.023">engage in risky sexual activities</a> and to <a href="https://doi.org/10.1038/s41598-021-93242-4">become obese</a>. Not all kids with ACEs take on risky activities, of course, but enough to contribute to ACEs’ health consequences.</p>
<p>Growing up in conditions that are consistently frightening or stressful affects the biology of developing bodies, <a href="https://pubmed.ncbi.nlm.nih.gov/24426793/">especially the development of the systems that regulate our reactions to threats</a>, from predators to viruses. ACEs are even associated with <a href="https://doi.org/10.1038/mp.2012.32">changes in our chromosomes</a> that are linked to early mortality. </p>
<h2>Interpersonal and psychological effects</h2>
<p>As psychiatrists for adults who experience physical and mental illness in combination, our patients often tell us about the personal impact of ACEs. One man said he did not “have even the slightest shadow of a doubt that a loss of human connection is the most substantial negative impact” of these experiences. The health costs of human disconnection are profound. Indeed, <a href="https://doi.org/10.1371/journal.pmed.1000316">lacking interpersonal support may hasten mortality as much or more than smoking, excessive drinking, inactivity, obesity or untreated high blood pressure</a>. </p>
<p>The psychological effects of ACEs may be more obvious and can include fearful expectations, a conviction that one is unworthy of love or protection, unregulated anger or shame and discombobulating memories of bad events. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of five red hot-air balloons rising into the air, with one held back by a large rock tied to it." src="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445498/original/file-20220209-25-rl380b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">ACEs greatly increase the risk of depression, anxiety disorders, post-traumatic stress disorder and addictions.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>It greatly increases the risk of depression, anxiety disorders, post-traumatic stress disorder and addictions. The one in three adults who experienced childhood sexual or physical abuse or witnessed interpersonal violence at home <a href="https://doi.org/10.1503/cmaj.131792">have at least twice the incidence of these disorders</a> compared to others.</p>
<p>And then the dominoes fall: mental illness greatly increases the likelihood, burden and consequences of physical illness. To give just one example, <a href="https://doi.org/10.1016/s0006-3223(03)00111-2">in the months after experiencing a heart attack, those who are depressed are several times more likely to die</a>.
So, we see that ACEs don’t only lead to one kind of trouble, but to many. </p>
<h2>Social determinants of health</h2>
<p>Finally, the burden of illness is not distributed fairly. Maintaining health is more challenging for those who are disadvantaged by poverty, lack of education, language barriers, discrimination and living with the continuing systemic harms of colonization and multi-generational trauma.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of a child climbing up one side of a pyramid in steady steps, helped by an adult. On the other side, another child climbs over a substance-using parent and struggles to find a route up the pyramid." src="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=521&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=521&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=521&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=655&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=655&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445493/original/file-20220209-19735-1q36hq5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=655&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Childhood trauma has a complex relationship with social determinants of health.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Childhood trauma has a complex relationship with these social determinants of health. On one hand, ACEs are not unique to marginalized groups and can occur across all strata of society. On the other hand, the risk of experiencing ACEs may be greater in some groups and the consequences of ACEs may multiply as social forces interact. </p>
<p>For example, <a href="https://doi.org/10.1016/s0749-3797(99)00084-7">childhood trauma is strongly associated with behaviours that increase the risk of sexually transmitted infections</a>. About <a href="https://doi.org/10.1016/j.psym.2014.10.006">half of the people living with HIV have experienced childhood abuse</a>. HIV is also more common in groups that face discrimination, including <a href="https://www.catie.ca/the-epidemiology-of-hiv-in-canada">men who have sex with men, people who use injectable drugs, Indigenous people</a> and <a href="https://www.ohtn.on.ca/research-portals/priority-populations/african-caribbean-and-black-communities/">immigrants from countries in which HIV is endemic</a>. </p>
<p>Intersecting components of personal experience and identity attract stigma and discrimination, which in turn influences mental health, self-care and one’s ability to navigate a healthcare system that has multiple barriers and gaps. <a href="https://doi.org/10.1016/j.psym.2014.10.006">It is a complex web and ACEs contribute to this complexity</a>.</p>
<h2>A cause of causes</h2>
<p>Events that occur in childhood may contribute to cascading health risks over one’s lifetime. There are so many paths to illness interacting with one another over decades and compromising health in so many ways, that it should be no surprise that <a href="https://doi.org/10.1016/s2468-2667(21)00237-1">childhood adversity is a profound public health problem</a>. </p>
<p>It is time that we, as a society, recognized ACEs as the malignant force that they are. Those affected need to be treated with compassion and also with awareness of the long-lasting effects of early adversity on health. Research that helps us understand the lifelong impact of ACEs could help guide prevention of chronic illnesses and mental health issues in the many people who experience adversity during childhood.</p><img src="https://counter.theconversation.com/content/176132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Maunder receives funding from Sinai Health and the University of Toronto as Chair of Health and Behaviour at Sinai Health and receives royalties from the University of Toronto Press for Damaged: Childhood Adversity, Adult Illness, and the Need for a Health Care Revolution.</span></em></p><p class="fine-print"><em><span>Jon Hunter receives funding from Sinai Health and is The Pencer Family Chair in Applied General Psychiatry at Sinai Health. He receives royalties from the University of Toronto Press for Damaged: Childhood Adversity, Adult Illness, and the Need for a Health Care Revolution. </span></em></p>One in three children experiences abuse or neglect. These adverse events increase lifelong risks for chronic diseases and mental health issues, creating a public health hazard hiding in plain sight.Robert Maunder, Professor of Psychiatry, University of TorontoJon Hunter, Professor of Psychiatry, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1573182021-03-18T01:32:42Z2021-03-18T01:32:42ZWhat is Mycoplasma genitalium, the common STI you’ve probably never heard of<figure><img src="https://images.theconversation.com/files/390232/original/file-20210317-21-14e4lym.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C998%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-man-hands-holding-his-crotch-769304695">from www.shutterstock.com</a></span></figcaption></figure><p><em><a href="https://www.fpv.org.au/for-you/sexually-transmissible-infections-blood-borne-viruses/mycoplasma-genitalium">Mycoplasma genitalium</a></em> (MG) is a sexually transmitted infection (STI) with many of the hallmarks of its better-known counterpart, <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/chlamydia">chlamydia</a>.</p>
<p>You can have MG without knowing it, or have symptoms; it can affect men and women, and it can be treated with antibiotics. </p>
<p>However, unlike chlamydia, we only have a limited number of antibiotics to treat it, due to a quirk in its cellular structure and the growing threat of antibiotic resistance. The antibiotics we need to use with resistant MG can also, uncommonly, have serious side-effects.</p>
<p>Here’s what you need to know about this common STI.</p>
<h2>What is it? How do I get it? How common is it?</h2>
<p>MG can affect both men and women, and is passed from person to person via their body fluids when they have sex. That can be via penile-vaginal sex or via penile-anal sex. Transmission via oral sex isn’t thought to be a big factor.</p>
<p>Several studies tell us MG is common, perhaps as common as chlamydia.</p>
<p>UK and US <a href="https://pubmed.ncbi.nlm.nih.gov/26534946/">data</a> <a href="https://pubmed.ncbi.nlm.nih.gov/33560093/">show</a> 1-2% of the adult population have it (making it about <a href="https://pubmed.ncbi.nlm.nih.gov/31794495/">as common as chlamydia</a>), and it is as common in men as in women. </p>
<p>In research yet to be published, when we tested women who walked through the door of our sexual health service in Melbourne, 6% had MG, which was as common as chlamydia (7%) in women in the same study. Of women with MG, roughly the same number had symptoms compared to no symptoms. When we tested <a href="https://pubmed.ncbi.nlm.nih.gov/30882306/">gay men without symptoms</a> who attended our service, 10% had MG.</p>
<p>However, we’re not entirely sure how many people are infected with MG throughout Australia. That’s because Australia has yet to set up a formal surveillance network (we’re in the middle of setting that up at the moment). MG is also not a notifiable disease yet. That means doctors or laboratories don’t have to tell health authorities when they have a case.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Mycoplasma genitalium, as 3D rendered image" src="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=300&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=300&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=300&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=377&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=377&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390234/original/file-20210317-21-1ghrluf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=377&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mycoplasma genitalium is a sexually transmitted infection that affects men and women.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/bacteria-mycoplasma-genitalium-3d-illustration-causative-1415788364">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<h2>How do I know if I have it?</h2>
<p>If you do have symptoms, these can resemble those of chlamydia. So the best thing is to go to your GP or sexual health clinic for a checkup, as the treatments are different.</p>
<p>If you’re a man with symptoms, they can vary from mild to moderate and include:</p>
<ul>
<li><p>mild irritation, an itch, or a burning sensation when urinating</p></li>
<li><p>a penile discharge, which may be clear or more like pus.</p></li>
</ul>
<p>For women, symptoms may include:</p>
<ul>
<li><p>a vaginal discharge</p></li>
<li><p>bleeding or pain with sex</p></li>
<li><p>abdominal pain (which may be a sign of <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/pelvic-inflammatory-disease-pid">pelvic inflammatory disease</a>).</p></li>
</ul>
<p>For men or women who have anal sex, symptoms may include:</p>
<ul>
<li>an itch or pain inside the anus, anal discharge and sometimes anal bleeding.</li>
</ul>
<p>Your doctor will take a urine sample for men and a vaginal swab for women. For men or women who have anal sex, they will take a rectal swab, or you will be instructed how to take it yourself. Samples will then be sent for laboratory testing.</p>
<h2>How is it treated?</h2>
<p>Once diagnosed, you’ll be treated with a course of oral antibiotics for about two weeks. Unfortunately, you may need several courses to cure the infection due to <a href="https://pubmed.ncbi.nlm.nih.gov/32622378/">increasing antibiotic resistance</a>. And some of these antibiotics can have side-effects. Occasional, but serious, side-effects include an abnormal heart rhythm, rupture of tendons and nerve damage.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-im-taking-antibiotics-when-will-they-start-working-107528">Health Check: I’m taking antibiotics – when will they start working?</a>
</strong>
</em>
</p>
<hr>
<h2>What happens if I leave it untreated?</h2>
<p>If the infection is left untreated in women, it can cause similar complications to chlamydia. Some women go on to develop <a href="https://pubmed.ncbi.nlm.nih.gov/32701123/">pelvic inflammatory disease</a>, although less commonly than with chlamydia. Pelvic inflammatory disease could, in turn, lead to infertility. If you’re pregnant, it can, uncommonly, lead to premature birth or miscarriage.</p>
<p>If left untreated in men there are no apparent complications but the main risk is men can infect new partners and reinfect treated partners. And for gay men, there’s <a href="https://pubmed.ncbi.nlm.nih.gov/19194271/">some data</a> to suggest a link between MG and HIV, although further studies are needed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-make-your-next-sexual-health-check-less-erm-awkward-72498">How to make your next sexual health check less, erm ... awkward</a>
</strong>
</em>
</p>
<hr>
<h2>Can I still be tested even if I don’t have symptoms?</h2>
<p>Current guidelines both <a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/mycoplasma-genitalium">in Australia</a> and <a href="https://www.bashhguidelines.org/current-guidelines/urethritis-and-cervicitis/mycoplasma-genitalium-2018/">internationally</a> recommend testing people with symptoms, or sexual contacts of known cases. They <a href="https://www.thelancet.com/action/showPdf?pii=S2589-5370%2821%2900059-6">don’t recommend doctors screen</a> people <a href="https://www.theguardian.com/australia-news/2021/mar/17/gps-urged-not-to-test-gay-men-for-sti-super-bug-over-fears-it-will-become-more-antibiotic-resistant">without symptoms</a>.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1371870337932132352"}"></div></p>
<p>When you screen, you have to be confident you have access to highly effective treatments, the treatments do not cause more harm than the condition itself and you have a good understanding of how often the condition progresses to cause complications.</p>
<p>For MG that balance is against screening currently. That’s because there are often no symptoms and we don’t yet fully understand how often the infection progresses to cause harm, although it seems to do so less often than chlamydia. The microorganism has also rapidly become so resistant to antibiotics we are having to use stronger and stronger ones, and multiple courses, to cure. This contrasts to chlamydia, which is easy to cure. </p>
<p>Not only do many antibiotics have side-effects, they affect the bacteria in people’s gut. These bacteria are important to keep us healthy, and if we bombard them with antibiotics it can affect our health and also lead to antibiotic resistance in a whole range of other bacteria, not just MG.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/157318/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catriona Bradshaw receives funding from the NHMRC and ARC (government funding). Melbourne Sexual Health Centre has also received research support from Speedx Pty Ltd and Hologic Pty Ltd which are manufacturers of diagnostic assays for Mycoplasma genitalium. </span></em></p>You can have this STI without knowing it, or have symptoms, it can affect men and women, and it can be treated with antibiotics. Left untreated, it may cause complications.Catriona Bradshaw, Professor, Head of Research Translation and Head of the Genital Mycoplasma and Microbiota Group, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1485752020-10-27T18:32:48Z2020-10-27T18:32:48ZCervical, breast, heart, bowel: here’s what women should be getting screened regularly<figure><img src="https://images.theconversation.com/files/365697/original/file-20201027-13-6krwme.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4740%2C3164&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Throughout the COVID-19 pandemic, many have felt anxious about going to the GP and other health facilities, believing these places have had a greater risk of transmission. A lot of us have also had to juggle work, childcare and home-based education.</p>
<p>So it’s not surprising the number of women attending for preventive health checks <a href="https://www.aihw.gov.au/reports/cancer-screening/cancer-screening-and-covid-19-in-australia/contents/how-has-covid-19-affected-australias-cancer-screening-programs">dropped alarmingly</a>. For example, 145,000 fewer breast cancer screenings were done between January and June this year than in the same period in 2018. It’s important, however, not to let the pandemic lead to avoidable poor health.</p>
<p>Here are some of the main health checks the the Royal Australian College of General Practitioners (RACGP) <a href="https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048-Red-Book-9th-Edition.pdf">recommends for women</a>. These checks are advised for women at average risk, but women who have a strong family history of any of these conditions should ask with their GP if they should start screening earlier or seek different types of testing.</p>
<h2>Cervical cancer screening</h2>
<p>The National Cervical Screening Program recommends cervical cancer screening every five years for women aged between 25 and 74.</p>
<p>In December 2017, a <a href="http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/cervical-screening-1">new test</a> was introduced for cervical cancer screening in Australia, and the testing interval changed from two years to five years. The change in testing interval was recommended because the new test is able to detect changes earlier. This means fewer women are tested each month, with the decline starting from December 2019.</p>
<p>Even accounting for this, the number of women tested in April and May 2020 fell sharply. There was some recovery in June, although rates in Victoria remain low. It used to be common practice to do a pelvic examination at the same time as a cervical screening test to look for problems in the uterus and ovaries, but this is no longer recommended due to its <a href="https://www.choosingwisely.org.au/recommendations/racgp8">poor accuracy</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=313&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=313&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=313&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=393&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=393&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365423/original/file-20201026-15-1cyhyyl.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=393&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Number of Medicare claims for routine cervical screening tests in Australia 2019-20.</span>
<span class="attribution"><span class="source">MBS Statistics Online</span></span>
</figcaption>
</figure>
<h2>Breast cancer screening</h2>
<p>Breast Screen Australia recommends an x-ray of the breasts, called a mammogram, every two years for women aged 50-74. Breast screening services were paused in April, but are now open again in all states, including Victoria.</p>
<p>Evidence for the benefits and harms of breast screening has been highly contested, so it’s important women make an informed choice. Cancer Australia states that for every 1,000 women screened for 25 years from the age of 50, around eight will avoid dying of breast cancer. On the other hand, eight women in every 1,000 screened will be treated unnecessarily (usually with surgery) for cancers that would <a href="https://www.canceraustralia.gov.au/publications-and-resources/position-statements/overdiagnosis-mammographic-screening">never otherwise have been diagnosed</a>.</p>
<p>Screening works by finding a cancer before a woman has any symptoms, but it also finds cancers that grow very slowly or even regress, and that would <a href="https://www.youtube.com/watch?v=sUn1Eyrf_Zs">never have caused symptoms</a>. More sensitive tests, such as MRI, find <a href="https://www.youtube.com/watch?v=n--VfNKEQ6g">more of these “overdiagnosed cancers”</a> than other tests.</p>
<p>Breast cancer survival has improved significantly in the past few decades, but most of this seems to be due to <a href="https://www.nejm.org/doi/full/10.1056/nejmoa1600249">improvements in treatment</a> rather than improvements in screening.</p>
<h2>Ovarian cancer</h2>
<p>Unfortunately, there is no method for early detection of ovarian cancer and the symptoms can be vague, often leading to late diagnosis.</p>
<p>The <a href="https://www.canceraustralia.gov.au/affected-cancer/cancer-types/ovarian-cancer/what-are-symptoms-ovarian-cancer">most common symptoms</a> are abdominal bloating, abdominal or pelvic pain, appetite loss, feeling full quickly, indigestion, urinary frequency or urgency, constipation, unexplained weight loss or gain, and unexplained fatigue.</p>
<p>Women who have any of these symptoms for more than a few weeks should see their GP.</p>
<h2>Sexually transmitted disease</h2>
<p>About 1 in 20 women in their 20s will have a chlamydia infection and 1 in 200 will have gonorrhoea. These increase the risk of pelvic inflammatory disease and infertility. HIV, Hepatitis B and syphilis are less common, but important to detect early.</p>
<p>There is no formal screening program but the RACGP encourages sexually active women younger than 30 to have regular testing, especially if there has been a change in sexual partner.</p>
<h2>Cardiovascular disease and diabetes</h2>
<p>The <a href="https://www.aihw.gov.au/reports/life-expectancy-death/deaths-in-australia/contents/leading-causes-of-death">leading causes</a> of death in women in Australia are dementia, heart attacks, strokes, and lung cancer. The risks of these can be reduced with good preventive health.</p>
<figure class="align-center ">
<img alt="A health worker taking an elderly patient's blood pressure" src="https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/365701/original/file-20201027-13-dcj659.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Women shouldn’t forget to get their blood pressure and cholesterol regularly checked.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>The RACGP recommends women have their blood pressure checked every two years from age 18, cholesterol every five years from age 45, and checks for diabetes and kidney disease when at risk (for example if you have a family history). GPs recommend a general health check for those aged 45 to 49, or a heart health check for those over 45, or Aboriginal or Torres Strait Islander people over 30.</p>
<p>Treating high blood pressure and cholesterol and reducing smoking rates has prompted a massive decline in Australian heart disease deaths since their peak in the 1960s. However, women are less likely to have all risk factors for heart disease checked, and <a href="https://heart.bmj.com/content/103/7/492.abstract?casa_token=5JRZyGi0Cm4AAAAA:nAr-ZoQNtjGSJ-80ksWxqc90h24ubcmDzyV3wfYQoRhE9p8tozsDAXjF_xbXm2GKkUTj_J1jS24">younger women are less likely</a> to be put on blood pressure or cholesterol-lowering medication than men with the same risk level.</p>
<h2>Bowel cancer</h2>
<p>Bowel cancer screening is recommended by the National Bowel Cancer Screening Program for all Australians every two years between ages 50 to 74. This is done by a stool sample test, using a kit mailed by the National Bowel Cancer Screening Program and returned by post. This screening <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001216.pub2/full?highlightAbstract=colourect%7Cscreening%7Ccolorectal%7Ccolorect%7Cscreen%7Ccancer%7Ccolourectal">reduces deaths</a> from bowel cancer by 16%.</p>
<p>GPs have worked hard to ensure their patients’ safety during the COVID-19 pandemic. But it’s also important the recommended preventive health checks are not delayed unnecessarily.</p>
<hr>
<p>This article previously stated that eight women in every 1,000 <em>diagnosed by screening</em> will be treated unnecessarily for breast cancers. In fact, eight women in every 1,000 <em>screened</em> will be treated unnecessarily. This has been corrected.</p>
<p>A previous version of this article said the National Bowel Cancer Screening Program was for people aged 50-75, this has now been amended.</p><img src="https://counter.theconversation.com/content/148575/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jenny Doust is a member of the RACGP and receives grant funding from the NHMRC.</span></em></p><p class="fine-print"><em><span>Gita Mishra receives funding from NHMRC, Commonwealth department of Health </span></em></p>Regular testing can mean potentially fatal diseases can be picked up and treated early.Jenny Doust, Clinical Professorial Research Fellow, The University of QueenslandGita Mishra, Professor of Life Course Epidemiology, Faculty of Medicine, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1380592020-05-07T15:01:27Z2020-05-07T15:01:27ZCoronavirus found in semen of young men with COVID-19<figure><img src="https://images.theconversation.com/files/333324/original/file-20200507-49546-dd8p45.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3997&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/sperm-cells-3d-rendered-illustration-551812099">vchal/Shutterstock</a></span></figcaption></figure><p>We don’t know much about SARS-CoV-2, the virus that causes COVID-19, but we are learning new things about it every day. The latest bit of the jigsaw puzzle comes from a small study conducted in China, which found SARS-CoV-2 RNA (the virus’s genetic code) in the semen of young COVID-19 patients. </p>
<p>The study, <a href="http://jamanetwork.com/journals/jamanetworkopen/fullarticle/10.1001/jamanetworkopen.2020.8292?utm_source=For_The_Media&utm_medium=referral&utm_campaign=ftm_links&utm_term=050720">published in JAMA Network Open</a>, involved 38 patients undergoing treatment for severe COVID-19 disease at Shangqiu Municipal Hospital in Henan province. Fifteen of the patients provided a semen sample during the acute phase of their illness and 23 shortly after recovering. In four of the 15 patients with acute disease and in two of the 23 recovering patients, SARS-CoV-2 RNA was found in the semen samples. </p>
<p>These new findings differ from the results of an earlier study <a href="https://www.ncbi.nlm.nih.gov/pubmed/32297920">involving 12 COVID-19 patients</a> and <a href="https://link.springer.com/article/10.1007/s40618-020-01261-1">a case report</a>. However, the earlier investigations focused on patients with mild disease after they had recovered, whereas the current study focused on hospitalised patients with severe disease, and all samples in this latest study were taken during disease or very shortly after recovery. In fact, all of the semen samples that were found to have viral RNA in recovering patients were taken at day two and day three after recovery. So the differences between the earlier studies and the current one are probably the result of differences in disease severity and the time of sampling.</p>
<h2>Immunoprivileged</h2>
<p>The testes, along with the eyes, placenta, foetus and central nervous system, are considered to be “immunoprivileged sites”, which means they are protected from severe inflammation associated with an immune response. This is probably an evolutionary adaptation that protects vital structures. So these are niches where viruses may be protected from the host immune response.</p>
<p>Immunoprivileged sites <a href="https://www.scientificamerican.com/article/a-private-place-where-hiv-zika-and-ebola-hide/">gained attention as places where viruses can persist</a> after disease recovery during the 2013-16 West African Ebola virus outbreak. Ebola virus remained detectable in the semen of some survivors for more than three years and Ebola virus transmission through sexual intercourse can occur months after the patient has recovered.</p>
<p>We don’t know what the implications of the latest findings are yet. The presence of viral RNA in the patients’ semen does not necessarily indicate the presence of infectious virus. So it will be critical to show whether infectious virus can also be isolated from the semen of SARS-CoV-2 patients and survivors.</p>
<p>If this is possible, the next question will be whether – as the current data suggests – SARS-CoV-2 is predominantly found in the semen of patients with severe disease or whether significant virus levels can also be detected in the semen of patients with mild disease – or, indeed, in the semen of asymptomatic people. </p>
<p>Even if these things are shown, it’s probably of minor concern for virus spreading during acute infection. Given the high contagiousness of SARS-CoV-2 by non-sexual routes, it is difficult to imagine how this could be substantially increased by sexual transmission. The only scenario where sexual transmission of SARS-CoV-2 might be a problem would be if the virus persisted in the testicles for extended periods, and if COVID-19 survivors could sexually transmit the virus after their recovery. </p>
<p>We need more studies to investigate whether this is possible. In the meantime, it would still be sensible for those recovering from COVID-19 to use a condom until further research is done to clarify how long infectious virus stays in semen.</p><img src="https://counter.theconversation.com/content/138059/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Sexually active men should consider wearing condoms during the pandemic.Peter Ellis, Lecturer in Molecular Biology and Reproduction, University of KentMark Wass, Reader in Computational Biology, University of KentMartin Michaelis, Professor of Molecular Medicine, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1183372019-06-10T20:08:08Z2019-06-10T20:08:08ZAround half of 17-year-olds have had sex and they’re more responsible than you think<figure><img src="https://images.theconversation.com/files/278261/original/file-20190606-2772-1u2sa6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Australia's teens get their sexual information from a variety of sources and seem to know a lot about STIs.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/plTEYtXwXok">Kevin Laminto/Unsplash</a></span></figcaption></figure><p>Just under half of year 10 to 12 students have had sex, according to research <a href="http://www.teenhealth.org.au">released today</a>. </p>
<p>They know more about sexually transmitted infections (STIs) than you might think and are using a variety of sources for their sexual health information.</p>
<p>But there’s room to improve condom use and STI testing for sexually active teens.
Only 13% of all those surveyed thought they were likely to get an STI.</p>
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<strong>
Read more:
<a href="https://theconversation.com/good-sex-ed-doesnt-lead-to-teen-pregnancy-it-prevents-it-60036">Good sex ed doesn't lead to teen pregnancy, it prevents it</a>
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<p>In 2018, we surveyed 6,327 secondary students in years 10 to 12 from across Australia in all kinds of schools, for the Sixth National Survey of Secondary Students and Sexual Health.</p>
<p>We asked them a range of questions about their sexual health. These included where they turned to for information about sexual health, and how often. We asked if they liked their sex education. And yes, we asked about their sexual activity, or lack of it.</p>
<p>All up, 47% of students told us they had sex – defined as vaginal and/or anal intercourse regardless of the gender of the partner. </p>
<p>That might sound a lot. But rest assured, it was age-dependent. Year 10s were much less likely to have had sex yet (34% had ever had sex) compared to year 11s (46%) and 12s (56%).</p>
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Read more:
<a href="https://theconversation.com/do-i-need-to-shave-my-pubic-hair-before-having-sex-114614">'Do I need to shave my pubic hair before having sex?'</a>
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<p>Recent US reports suggest <a href="https://www.theatlantic.com/magazine/archive/2018/12/the-sex-recession/573949/">teens are having less sex</a> than they used to. The US Centers for Disease Control found between 1991 and 2017 the percentage of students who’d had intercourse dropped from 54% to 40%.</p>
<p><a href="http://www.publish.csiro.au/SH/SH14113">In Australia</a> since 2012, the rate has dropped 3% from 50%, which is within the margin of error, meaning there might be no actual decline.</p>
<p>The average age at which students had begun engaging in various sexual activities ranged from 13 for masturbation to 15 for mutual touching and oral sex. </p>
<p>The average age for the 47% who had experienced sexual intercourse in our survey was about 16 years old. This is slightly lower than other researchers <a href="http://www.publish.csiro.au/SH/SH14113">have found</a>. But our survey results may not represent Australian teens as a whole.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/278266/original/file-20190606-2750-1v8bek1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Of teens who were sexually active, most were in a relationship or had a partner about the same age.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/6mRo659CPmM">Japheth Mast/Unsplash</a></span>
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<p>Of those who were sexually active, most (76%) were having sex in their homes, in a relationship (65%) or with a partner about the same age as them (86%). </p>
<p>They largely reported responsible behaviours. These included discussing having sex (81%) beforehand and protecting their health (77%). They used condoms (56%) and/or the pill (41%).</p>
<p>In short, teens in Australia are doing pretty well in relation to sex. And this isn’t new: the findings echo what has been seen in previous versions of the same survey over the past 25 years.</p>
<h2>How about unwanted sex?</h2>
<p>We also continue to find about a quarter (28%) reported some kind of unwanted sex at some point in their lives. </p>
<p>“Unwanted” means very different experiences for different people. A quarter (23%) of those reporting unwanted experiences wrote in comments. Many suggested it was a sense of “meh” or “just wasn’t really into it at the time”. But they provided no indication of regret.</p>
<p>While the survey did not ask about rape or sexual assault, slightly less than 1% of all participants did write explicitly about such experiences.</p>
<p>Despite this, we found 93% wanted their last sexual encounter. Overall, 85% indicated they felt extremely good and happy about their last experience and fewer (less than 20%) reported feeling upset, worried or guilty. </p>
<p>Shifts in school-based sex education to include a greater emphasis on relationships and skills in communication might, in part, explain the good sex teens are reporting.</p>
<h2>How about smartphones and sexting?</h2>
<p>Some things have changed, like using the internet to find sexual health information. That’s almost double what was reported in 2013 (44% then, 79% now). This isn’t surprising, given the pervasiveness of the internet today – 88% did the survey on an internet-enabled mobile device.</p>
<p>Rates of sexting seemed to have gone down by about 3% across each of the specific behaviours asked about. Overall about a third of students had engaged in some form of sexting. For those who were sexting, it was mostly with a partner or friend and only a few times in the previous two months.</p>
<h2>Good marks, but room for improvement</h2>
<p>So when it comes to sex and sexual health, Australia’s students are receiving pretty good marks. But there is room to continue improving.</p>
<p>The levels of reported unwanted sex, and the complexity of it, suggest a more nuanced approach may be warranted. Talking to teens about unwanted sex could expand beyond rape, sexual assault and issues of consent to cover communicating about desires and pleasure in a relationship leading to hopefully less “meh”.</p>
<p><a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">Rates of STIs</a> among young people suggest there is room to improve condom use and testing among sexually active teens. Only 13% thought they were likely to get an STI.</p>
<p>Luckily, Australian teens are having healthy conversations with partners, part of realising a happy, healthy and pleasurable sex life.</p>
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<strong>
Read more:
<a href="https://theconversation.com/how-to-make-your-next-sexual-health-check-less-erm-awkward-72498">How to make your next sexual health check less, erm ... awkward</a>
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<img src="https://counter.theconversation.com/content/118337/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher M Fisher receives funding from the Commonwealth Department of Health. </span></em></p>Australia’s year 10-12 students are getting good marks when it comes to sexual health, according to new research out today. But there’s room for improvement.Christopher M Fisher, Associate Profressor in Young Peoples Sexual Health & Sex Education, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1096582019-02-13T02:06:38Z2019-02-13T02:06:38ZSyphilis is making a come-back, and causing some unusual health problems<figure><img src="https://images.theconversation.com/files/258451/original/file-20190212-174883-g9w2gc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Syphilis can cause vision loss, and it's on the rise. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>Syphilis is a sexually transmissible infectious disease that has plagued humankind for centuries. Today, syphilis is diagnosed rapidly by a simple blood test, and easily treated with an inexpensive antibiotic. However, the disease may masquerade as other medical conditions, confusing even health care professionals. A delay in diagnosis and treatment may have serious medical consequences.</p>
<p>There’s ongoing debate about the origin of syphilis, but the disease is <a href="https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/">well described in the medical literature</a> from the Middle Ages. The name “syphilis” was coined in 1530 by an Italian physician. Dr. Girolamo Fracastoro wrote a poem describing features of the illness in a fictional shepherd named Syphilus, who had blasphemed against the Sun-God and was punished with a severe case of the disease.</p>
<p>Since this time, syphilis has claimed many lives and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956094/">influenced civilisation</a> in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1048214/">diverse ways</a>. </p>
<p>Syphilis has afflicted heads of state, whose nations have suffered from the consequences of their diminished mental health. King Henry VIII of England and Tsar Ivan IV Vasilievici of Russia (“Ivan the Terrible”) are examples. Careers of internationally influential artists – such as Ludwig van Beethoven, Oscar Wilde and Scott Joplin – ended prematurely due to syphilis. </p>
<p>Public outrage over the highly unethical <a href="https://www.history.com/news/the-infamous-40-year-tuskegee-study">Tuskegee study</a> and Guatemalan experiments on people with untreated syphilis have helped to shape present day human research regulations.</p>
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Read more:
<a href="https://theconversation.com/three-charts-on-the-state-of-stis-and-blood-borne-viruses-in-australia-86298">Three charts on the state of STIs and blood-borne viruses in Australia</a>
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<h2>Cause and effect</h2>
<p><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32411-4/fulltext">Syphilis is caused by</a> a spiral shaped bacterium called Treponema pallidum. Although the <a href="https://www.nature.com/articles/nrdp201773">bacteria multiply slowly</a>, they are easily passed between sexual partners via the skin or mucous membranes. </p>
<p>A small ulcer is the typical “first stage” of syphilis. The ulcer does not appear until several weeks after the sexual encounter, and it is painless, short-lived and heals without a trace. So it may go unnoticed, especially if it occurs in an inconspicuous place, inside vaginal or rectal passages, or in the mouth.</p>
<p>The second stage of syphilis is characterised by unusual skin and mucous membrane rashes that improve without treatment over weeks to months. The disease then enters a period called the latent stage that lasts for years, during which a person has no symptoms, but continues to be infected.</p>
<p>Finally, in the tertiary stage, syphilis becomes <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32411-4/fulltext">extremely destructive</a>. Large inflammatory growths that occur anywhere in the body may seriously damage tissues. There may be aneurysms, heart disease, dementia and paralysis. </p>
<p><a href="https://www.nature.com/articles/nrdp201773">Syphilis can also be passed</a> from a pregnant woman to her unborn child, resulting in a serious illness and sometimes loss of the baby.</p>
<p>Throughout the course of syphilis, the nervous system and senses may become affected, <a href="https://www.nature.com/articles/s41598-018-30559-7">causing unusual health problems</a>. This includes inflammation inside the eye, called uveitis. Syphilitic uveitis causes vision loss in about two-thirds of people who develop it, and may lead on to other eye conditions, such as cataract, glaucoma, retinal scarring and retinal detachment.</p>
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<a href="https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/258626/original/file-20190213-90491-du67d2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Oscar Wilde is one of many well-known people throughout history who suffered from syphilis.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<h2>Treatment</h2>
<p>Introduction of penicillin into medical practice in the 1940s provided an opportunity to eradicate syphilis, as Treponema is highly sensitive to this antibiotic. In countries where testing and antibiotics were readily available, rates of syphilis dropped to extremely low levels during the 20th century. </p>
<p>In Australia in 2010, there were just <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">five reported new infections</a> per 100,000 people. Hope was high that the same might be achieved in low income, developing nations.</p>
<p>Unexpectedly, however, rates of syphilis are climbing in high income countries across the globe. <a href="https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance">Latest figures</a> from the Kirby Institute indicate an increase by over 250% between 2010 and 2017, affecting both Australian men and women. </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5354565/">Many factors are responsible</a>. Aware of the highly effective drugs for HIV infection, people are less concerned about safe sex. Other factors that promote spread of the Treponema bacteria are high levels of travel and new drugs for sexual dysfunction. There is also a relationship between HIV infection and syphilis: having one infection increases the risk of catching the other. </p>
<p>This creates a challenging situation for health care professionals, who are suddenly encountering patients with a disease they did not focus on during their training. Add to this that syphilis may masquerade as a wide range of other medical conditions as it moves past the first stage. It is actually referred to in clinical textbooks as the Great Imitator or the Great Mimicker.</p>
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<strong>
Read more:
<a href="https://theconversation.com/stigma-and-lack-of-awareness-stop-young-people-testing-for-sexually-transmitted-infections-80265">Stigma and lack of awareness stop young people testing for sexually transmitted infections</a>
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<hr>
<h2>Ocular syphilis</h2>
<p>As ophthalmologists we have noticed an increase in cases of syphilitic uveitis. A delay in starting penicillin can result in permanent vision loss. In one <a href="https://www.nature.com/articles/s41598-018-30559-7">very large study conducted in Brazil</a>, it took about three months to recognise syphilis as the cause of uveitis, and half of people in the study did not fully recover their vision despite taking antibiotics.</p>
<p>Ophthalmologists who specialise in uveitis identify the lack of medical suspicion for the diagnosis of syphilis as an <a href="https://bjo.bmj.com/content/early/2019/01/30/bjophthalmol-2018-313207">important reason for a delay</a> to starting treatment.</p>
<h2>Prevention</h2>
<p>There is no vaccine for syphilis, and a person may catch it <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32411-4/fulltext">more than once</a>. But there are ways to avoid the health problems caused by syphilis. Practising safe sex protects against – but does not completely prevent – the disease. </p>
<p>Testing is key. It involves checking the blood for antibodies against Treponema bacteria. The <a href="https://www.nature.com/articles/nrdp201773">test</a> is inexpensive and you get results within a day.</p>
<p>Anyone who is sexually active can ask for a <a href="https://www.cdc.gov/std/syphilis/Syphilis-June-2017.pdf">test</a>, but certain situations should trigger a test: pregnancy; HIV infection or sexually transmissible infections; and a partner with syphilis. <a href="https://bjo.bmj.com/content/early/2019/01/30/bjophthalmol-2018-313207">Doctors</a> may also suggest a test for rashes or ulcers, and for some inflammatory problems, such as uveitis. Everyone from the general public to our health-care professionals need to be more aware of syphilis.</p><img src="https://counter.theconversation.com/content/109658/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justine R. Smith receives funding from the National Health & Medical Research Council (NHMRC) and the Ophthalmic Research Institute of Australia. She is a Science & Technology Australia Superstar of STEM.</span></em></p><p class="fine-print"><em><span>João M. Furtado does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As ophthalmologists, we’ve noticed an uptick in cases of vision problems caused by syphilis. Practising safe sex is important for our eye health too.Justine R. Smith, Professor of Eye & Vision Health, Flinders UniversityJoão M. Furtado, Associate Professor of Ophthalmology, Universidade de São Paulo (USP)Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/943022018-04-05T06:41:03Z2018-04-05T06:41:03Z‘Super gonorrhoea’ raises the stakes in the war against superbugs<figure><img src="https://images.theconversation.com/files/213320/original/file-20180405-189798-nbplrq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Antibiotic resistance is not new but recent developments increase the urgency for action.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>There has been a lot of news over the past few weeks about the rise of superbugs and antibiotic overuse, including a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">nasty sexually transmitted infection</a> in the United Kingdom. A British man is the first in the world to be diagnosed with a strain of gonorrhoea resistant to all strains of antibiotics used to treat the infection. </p>
<p>Superbugs have tended to pose the greatest risk to people with compromised immune systems, such as cancer patients, and those who were injured or underwent surgery. But the sexual transmission of these bugs means antibiotic resistant infections can spread much more widely.</p>
<p>So what exactly are superbugs, and how scared should we be?</p>
<h2>Super but not new</h2>
<p>“Superbugs” aren’t the bug equivalent of superheroes. The term describes bacteria that have become resistant to antibiotics. How “super” they are depends on how many antibiotics they have become resistant to. </p>
<p>“Antibiotic resistance” and “drug-resistant infections” also refer to the same phenomena. They describe microorganisms that have evolved to become impervious to being killed by treatment with antibiotics. </p>
<p>There is a common misconception that antibiotic resistance means your body has become resistant to antibiotics. This is not true.</p>
<p>Antibiotic resistance is nothing new. Alexander Fleming’s 1945 <a href="https://www.nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf">Nobel Prize acceptance speech for the discovery of penicillin</a> discusses the development of resistance. He includes a scenario of Patient X, who:</p>
<blockquote>
<p>buys some penicillin and gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife. Mrs. X gets pneumonia and is treated with penicillin. As the streptococci are now resistant to penicillin the treatment fails.</p>
</blockquote>
<p>Indeed, resistance has been reported for <em>every</em> antibiotic ever introduced – <a href="https://antimicrobialresistance101.files.wordpress.com/2015/04/antibiotic-resistance-history-graph.png">generally within a few years</a> of deployment.</p>
<h2>How do they become resistant?</h2>
<p>Bacteria are able to fight antibiotics by a variety of methods:</p>
<ul>
<li>They build stronger cell walls to stop the drugs from entering</li>
<li>They actively spit them out so the antibiotic can’t reach a lethal concentration inside the cell</li>
<li>They produce enzymes that modify and inactivate the antibiotics and</li>
<li>They alter the target of the antibiotic so it no longer interacts with the drug.</li>
</ul>
<p>One or more of these resistance mechanisms may already be naturally present in a very small fraction of the millions of bacteria exposed to an antibiotic. This is called “innate resistance”. Most of the bacteria are killed, but this small population survives and grows. </p>
<p>In other cases, resistance develops through evolution (a process known as “induced resistance”). Bacteria grow rapidly. Under optimal conditions the population can double in as few as 15-30 minutes. </p>
<p>When exposed to sub-lethal doses of antibiotic, bacteria can become tolerant. They accumulate beneficial mutations over multiple generations. They then pass on this resistance to their progeny when they divide.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-know-why-bacteria-become-resistant-to-antibiotics-but-how-does-this-actually-happen-59891">We know _why_ bacteria become resistant to antibiotics, but _how_ does this actually happen?</a>
</strong>
</em>
</p>
<hr>
<p>Bacteria are also very promiscuous. They exchange pieces of genetic material (plasmids) that carry the codes for resistance. This allows for the rapid spread of resistance between different types of bacteria. </p>
<p>An example is highlighted by <a href="https://www.theaustralian.com.au/news/world/the-times/drug-resistance-spreads-to-humans-at-shocking-rate/news-story/fc0d3487e6f353a1f4569c1770721d34">recent news reports</a> of resistance to a “last resort” antibiotic, colistin. A gene called mcr-1 (mobilized colistin resistance) was found to be contained in plasmids in <em>E. coli</em> bacteria collected from Chinese pig farms in 2011 (<a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(15)00424-7/fulltext">though it was not reported until 2015</a>). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213326/original/file-20180405-189816-h2h0lq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A gene that makes bugs resistant to antibiotics of ‘last resort’ was found in Chinese pig farms.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1060871903?src=8TKC8hWSjSmYq38tXIvwjw-1-22&size=medium_jpg">Zawinul/Shutterstock</a></span>
</figcaption>
</figure>
<p>While colistin resistance was already known, the potential for resistance to be quickly spread by this new mechanism is of great concern. For some infections, colistin is the only antibiotic that still works. Indeed, the mcr-1 gene has now been found in <a href="https://www.nature.com/articles/s41467-018-03205-z">multiple types of bacteria in more than 30 countries</a> (including a <a href="http://www.cidrap.umn.edu/news-perspective/2016/05/highly-resistant-mcr-1-superbug-found-us-first-time">patient in the United States in 2016</a>).</p>
<p>The <a href="http://www.searo.who.int/mediacentre/releases/2015/1612/en/">World Health Organisation is now warning</a> that we face a return to a “pre-antibotic era”. It warns:</p>
<blockquote>
<p>Common infections and minor injuries which have been possible to treat for decades may once again kill millions. Resistance to antibiotics will make complex surgeries and management of several chronic illnesses like cancer extremely difficult.</p>
</blockquote>
<p>Before antibiotics, 40% of deaths were due to infection. If we do not act, <a href="https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf">a review commissioned by the United Kingdom government</a> predicts that by 2050 drug-resistant infections could cause 10 million annual deaths.</p>
<h2>How did we get here?</h2>
<p>This rise in resistance is largely driven by excessive antibiotic use. The same UK report indicates that up to two-thirds of the world’s antibiotics are not used to treat humans, but are given to animals grown for food. This animal use is often as a food additive, not as therapeutic treatment for an infection. </p>
<p>Of the remaining antibiotics used in humans, up to two-thirds may be inappropriately prescribed. </p>
<p>This huge overuse of antibiotics inevitably drives the development of resistance by unnecessarily exposing a much greater population of bacteria to antibiotics. Sub-lethal concentrations, such as in waste water from farms, fosters resistance. </p>
<p>Alarmingly, <a href="http://www.pnas.org/content/early/2018/03/20/1717295115">a recent study</a> shows that <a href="https://www.theguardian.com/science/2018/mar/26/calls-to-rein-in-antibiotic-use-after-study-shows-65-increase-worldwide">our use of antibiotics is increasing even more</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-health-and-agriculture-sectors-need-to-work-together-to-stop-antibiotic-resistance-69031">Why the health and agriculture sectors need to work together to stop antibiotic resistance</a>
</strong>
</em>
</p>
<hr>
<p>So, given we already have <a href="https://www.statnews.com/2017/01/12/nevada-woman-superbug-resistant/">people dying from bacteria resistant to all known antibiotics</a>, and these bacteria are <a href="https://apnews.com/afcee30eb24848d38f9b855fbcc9a4ba">becoming increasingly prevalent</a>, what’s stopping a global pandemic tomorrow? </p>
<p>It really comes down to the fact that, unless you’re immunocompromised or have an injury allowing the bacteria to get into your body, most bacteria aren’t particularly effective at spreading infections. </p>
<p>This is why the <a href="https://news.nationalgeographic.com/2018/03/gonorrhea-evolving-untreatable-spd/">reports</a> of a <a href="https://www.theguardian.com/commentisfree/2018/mar/30/super-gonorrhoea-antibiotic-crisis-drug-resistant-bugs">“super-gonorrhea” case in the UK </a> are alarming. The sexually transmitted bacteria (<em>Neisseria gonorrhoeae</em>) <a href="http://www.who.int/mediacentre/news/releases/2017/Antibiotic-resistant-gonorrhoea/en/">causes nearly 80 million infections a year</a>. This bacteria now has the potential to carry and spread high levels of antibiotic resistance through a much larger population of both people and other bacteria.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/213325/original/file-20180405-189821-p2j2no.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Super-gonorrhea has the potential to spread antibiotic resistance to many more people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/white-mattress-after-waking-morning-sun-1058016380?src=idJzfv5Tw4DqSyPgT08sBA-1-42">The Five Aggregates/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Fight against superbugs</h2>
<p>It’s not all doom and gloom. Nations and international organisations are increasingly devoting attention and resources to fight the rise of antibiotic resistance. Strategies include more sparing use of existing antibiotics, and <a href="https://longitudeprize.org/">investment and incentives to develop diagnostics</a> that can decide when antibiotics are needed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/when-the-drugs-dont-work-how-we-can-turn-the-tide-of-antimicrobial-resistance-71711">When the drugs don’t work: how we can turn the tide of antimicrobial resistance</a>
</strong>
</em>
</p>
<hr>
<p>Non-antibiotic approaches, such as vaccines, phage therapy, and microbiome manipulation, are garnering increased consideration. </p>
<p>Initiatives to re-invigorate the discovery of new antibiotics include efforts such as <a href="https://www.gardp.org/">The Global Antibiotic Research & Development Partnership</a>, the <a href="http://www.carb-x.org/">Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator</a>, and Australia’s own global effort to crowdsource antibiotics from international chemists, <a href="http://www.co-add.org">The Community for Open Antimicrobial Drug Discovery</a>. </p>
<p>We must keep our attention on the threat posed by drug resistant infections and invest in antimicrobial research to keep the potential global catastrophe at bay.</p><img src="https://counter.theconversation.com/content/94302/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Blaskovich receives funding from the NHMRC, Australian Academy of Technology and Engineering, the Aiustralian Department of Industry, Innovation and Science, and the Wellcome Trust for antibiotic-related research. He works for the Community for Open Antimicrobial Drug Discovery, an initiative to discover new antibiotics. He is an inventor on several patents describing new antibiotics.</span></em></p>Superbugs used to pose the greatest risk to people with compromised immune systems and those who had surgery. But their sexual transmission means antibiotic resistance can spread much more widely.Mark Blaskovich, Senior Research Officer, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/674312016-11-29T15:57:23Z2016-11-29T15:57:23ZWhere Latino teens learn about sex does matter<figure><img src="https://images.theconversation.com/files/147821/original/image-20161128-22732-1qx06dk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-200190815/stock-photo-rear-view-of-a-bunch-of-high-school-students-walking-down-the-hallway.html?src=prZXSt33kNMLILAufcKDJg-1-28">Image of teens walking via www.shutterstock.com.</a></span></figcaption></figure><p>The <a href="http://abcnews.go.com/US/teen-pregnancy-rates-hit-historic-lows-cdc-finds/story?id=38739305">U.S. teen pregnancy rate is at a historic low</a>, with the number of teen births declining dramatically over the past decades. </p>
<p>But there are disparities among groups of teens. <a href="http://www.hhs.gov/ash/oah/adolescent-health-topics/reproductive-health/teen-pregnancy/trends.html">Latina teens have the highest teen birth rate</a> of any racial or ethnic group. <a href="http://www.cdc.gov/nchhstp/healthdisparities/hispanics.html">Latino teens are also more affected by STIs</a> – particularly chlamydia, syphilis, and gonorrhea – than their white peers. Sexually active Latino teens are also <a href="http://www.cdc.gov/nchhstp/newsroom/docs/2012/YRBS-Fact-Sheet-072312-508.pdf">less likely to use condoms</a> and other forms of contraception. </p>
<p>Sexual exploration during adolescence is normal and healthy. These disparities are a sign that many Latino teens have unmet needs when it comes to information about sexual health and relationships. </p>
<p>Prior research has found that teens’ source of sex information <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860278/">is related to their beliefs about sex</a> and sexual behaviors. And today teens get information about sex from <a href="https://www.guttmacher.org/fact-sheet/facts-american-teens-sources-information-about-sex">a variety of sources</a>, including their parents, peers, school and digital media. </p>
<p>Understanding where teens learn about sex and how that influences them can help us find ways to encourage healthy sexual behaviors, such as using condoms and birth control. </p>
<p>But despite these disparities, and the fact that Latinos are also the largest ethnic or racial minority in the U.S. (constituting <a href="https://www.census.gov/quickfacts/table/PST045215/00">17 percent of the population</a> and <a href="http://www.hhs.gov/ash/oah/adolescent-health-topics/americas-adolescents/changing-face.html">23 percent of all youth</a>), there is very little research about where Latino teens are getting information about sex. </p>
<h2>Where Latino teens get information about sex</h2>
<p>To find out more about which sources are most relevant to Latino teens, we surveyed nearly 1,200 Latino ninth graders at 10 different high schools in Los Angeles. </p>
<p>In the survey, teens had to select their “most important source of information about sex and relationships while growing up” from a list of 11 options. Rather than asking about the many sources of information they have encountered, we wanted to know which one they felt was most important in their lives. </p>
<p>Parents were the most commonly listed source, with 38 percent saying their parents were their most important source of information about sex and relationships. These findings are similar to surveys of <a href="https://thenationalcampaign.org/sites/default/files/resource-primary-download/wov_2012.pdf">teens from other racial and ethnic groups</a>, who report that parents are the most important influence on their decisions about sex.</p>
<p>For some teens in our study, different sources – including other family members (17 percent), classes at school (13 percent) and friends (11 percent) – fill this important role. </p>
<p>Although <a href="http://www.advocatesforyouth.org/publications/publications-a-z/438-television-and-the-internet-important-sources-of-sexual-health-information-for-youth">other studies</a> have found that teens often rely on media and the internet for sexual health information, teens in our study rarely mentioned them as their most important source. That doesn’t mean they aren’t accessing information about sex online or hearing about sex on TV, but that they do not necessarily see these as the most important source in their lives.</p>
<h2>Where teens learn about sex matters</h2>
<p>We also wanted to know if there was a connection between Latino teens’ most important source of sex information and their intentions to use condoms in the future.</p>
<p>Overall, most teens in our study planned to use condoms the next time they had sex, with 71 percent of teens saying that they “definitely will” and 22 percent saying that they “probably will.” But did their preferred source of information about sex matter in this decision? </p>
<p>We compared the influence of parents, other family members, friends, boyfriends or girlfriends, schools, health care providers and media on teens’ intentions to use condoms.</p>
<p>After controlling for other factors known to be linked to teens’ sexual behaviors, such as age, gender and sexual experience, we found that these Latino teens’ stated most important source of sex information <a href="http://heb.sagepub.com/content/early/2016/10/05/1090198116671704.abstract">was significantly related to their intentions</a> to use condoms in the future. In other words, there is a connection between where teens get information about sex and their future sexual behaviors. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/146832/original/image-20161121-4535-qxc7lf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-467470997/stock-photo-background-of-colored-condoms-blue-green-gold-condoms-on-white-background.html?src=ZfXahIxIFF-Q4X21ibYtTQ-2-6">Condoms image via www.shutterstock.com.</a></span>
</figcaption>
</figure>
<p>We then compared the influence of other sources of sex information to the influence of parents.</p>
<p>Teens who reported that their family members, classes at school, health care providers, boyfriends or girlfriends, or the media were their main source of information about sex reported similarly high intentions to use condoms to teens who listed their parents as most important. </p>
<p>However, the teens who turned to their friends for sex information were less likely to say they planned to use condoms than teens who turn to their parents. This is not too surprising. Teens who rely on friends as their primary source of sex information may be more vulnerable to peer pressure to avoid using condoms or may be getting misinformation about their effectiveness. </p>
<p>The primary source of sex information was particularly important for the boys’ intentions to use condoms in the future. The boys who rely on friends or media and internet as their main sources for sex information were significantly less likely to report planning to use condoms than the boys who turned to their parents. </p>
<p>Boys who do not have a trusted adult who they can rely on for sex information may be seeking out sources that could also spread negative messages about condoms, such as “locker room talk” with peers or pornography online. </p>
<h2>Encouraging positive conversations about sex</h2>
<p>These findings highlight the importance of providing comprehensive sources of sex information for Latino teens at home, in their schools and in the community.</p>
<p>Unfortunately, we don’t know how these results compare to other groups of teens. Not enough research has been done on how the various sources of sex information may influence teens’ sexual behavior, and there is a need for more studies on this topic.</p>
<p>Given that parents are a popular and important source of information for many teens, <a href="https://thenationalcampaign.org/resource/families-talking-together-creating-healthy-family-conversations-prevent-teen-pregnancy">interventions that empower parents</a> to talk to their kids about sexuality, relationships and sexual health and provide them with accurate information could help.</p>
<p>It may be beneficial to include other family members such as grandparents, aunts, uncles, cousins and siblings in these interventions so they too can provide accurate information when teens turn to them. </p>
<p>Encouraging positive family conversations about sex and relationships will help young people make healthier decisions and grow into sexually healthy adults. </p>
<hr>
<p><em>The disclosure statements for this article have been updated to include the Public Health Institute in Oakland, California.</em></p><img src="https://counter.theconversation.com/content/67431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work was supported by Planned Parenthood-Los Angeles, the William and Flora Hewlett Foundation, and the Ford Foundation through funding to the Public Health Institute in Oakland, CA. The sponsors had no involvement in the study design; in the collection, analysis and interpretation of data; or in the writing of the research article.The study was conducted while both authors were at the Public Health Institute. </span></em></p>Understanding where teens learn about sex and how that influences them can help us find ways to encourage healthy sexual behaviors, such as using condoms and birth control.Nancy Berglas, Public Health Researcher, Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, University of California, San FranciscoJillian Eversole, Education & Communications Coordinator, Bixby Center for Global Reproductive Health, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/575922016-04-12T15:22:44Z2016-04-12T15:22:44ZHow sexually transmitted diseases might have driven the evolution of monogamy<figure><img src="https://images.theconversation.com/files/118308/original/image-20160412-15880-cbokbu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bride and groom, 1900-1910.</span> <span class="attribution"><span class="source">wikimedia</span></span></figcaption></figure><p>Exactly why so many humans choose monogamous pair bonds over juggling multiple partners has long been a mystery to scientists. After all, having several partners at the same time should lead to more offspring – an outcome you’d think evolution would favour. Now a <a href="http://nature.com/articles/doi:10.1038/NCOMMS11219">new study</a> has linked the phenomenon to sexually transmitted diseases, arguing that monogamy could have evolved because it offered protection against the threat of infection.</p>
<p>Monogamy is, of course, the norm in Western societies. But there are many cultures where a husband can have more than one wife (<a href="http://www.britannica.com/topic/polygyny-marriage">polygyny</a>) or, less commonly, a wife can have more than one husband (<a href="http://www.theatlantic.com/health/archive/2013/02/when-taking-multiple-husbands-makes-sense/272726/">polyandry</a>). This diversity of human mating systems is also hard to explain. <a href="http://www.sciencedirect.com/science/article/pii/S0376635700001182">What we do know</a>, however, is that many hunter-gatherer societies, living in small groups, were most often polygynous (and many remaining groups still are). But with the rise of agriculture, societies tended to become more complex – and less polygynous. In the most strictly monogamous societies, there was often a social punishment for polygynists, either informally or, as in many modern societies, through a legal system. </p>
<p>Many explanations for this evolution have been put forward, including changes to the way that women chose their partners, such as <a href="https://theconversation.com/modelling-monogamy-and-the-original-sexual-revolution-7340">being faithful to men</a> who invested in provisioning for them. Another possibility is that groups of monogamists may have performed better than groups of polygynists. But the new research adds a further option: could an increased risk of infection from sexually transmitted infections associated with polygyny have contributed to – or even driven – the overall move from polygyny to monogamy? </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118332/original/image-20160412-15868-1dt7zwd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Northern Namibia’s indigenous Himba people, some of whom are hunter-gatherers, are polygynist.</span>
<span class="attribution"><span class="source">Hans Stieglitz/wikimedia</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Sexually transmitted diseases have been infecting humans for a long time. Prior to modern medicine, they also often caused significant harm – especially to the reproductive system. Clearly, these diseases infect polygynists more than monogamists, and it <a href="http://www.ncbi.nlm.nih.gov/pubmed/9108946">has been argued</a> that when a polygynist and a serial monogamist have the same number of partners overall, the polygynist is more likely to pick up a dose of something nasty than the monogamist. According to computer modelling, this is because contact networks are more connected when you have concurrent partners than when you have serial partner change. Either way, overall, these effects could have had a big enough impact on the well-being of polygynists to allow monogamous individuals to take over a population. </p>
<h2>The challenges of modelling</h2>
<p>It’s certainly a good argument. But it’s hard to assess how likely it is to be true. This is because we know very little about the risk of sexually transmitted diseases in hunter-gatherer societies or historical societies transitioning to agriculture. This is a common problem in science: we can only make progress when we can test an idea, but plausible ideas are sometimes very hard to evaluate without massive effort.</p>
<p>One option in these cases is to do your experiment in the form of a computer simulation. This is what the researchers behind the new study did, modelling the impact of a bacterial sexually transmitted disease <a href="https://theconversation.com/health-check-the-sti-check-up-warts-and-all-32160">similar to gonorrhoea or chlamydia</a>. Their results strongly back the hypothesis that such diseases could have triggered monogamy. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=263&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=263&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=263&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=331&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=331&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118329/original/image-20160412-15871-16wvcvu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=331&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Light blue means polygamy is permitted while dark blue means it is not fully criminalised. Black means fully outlawed.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/Polygyny#/media/File:Legality_of_polygamy.png">wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>In their model, sexually transmitted diseases tend to “fade out” from small groups such as polygynist hunter-gatherers. This occurs because of random chance events that are more likely to be important in small groups, such as all the infected people suddenly getting better or dying. In larger, agricultural groups, however, such fade-out is much less likely, so sexually transmitted diseases tend to persist, damaging the health and reducing the birth rates of polygynists while allowing monogamists to take over. </p>
<p>What’s more, the monogamists that are most likely to take over a group for a long period are those that follow a “punishment strategy”, which fits with what we observe in many societies today.</p>
<p>So is the puzzle solved? Not quite yet. Computer simulations are useful and can tell us important things, but they are always limited and necessarily simplify the real world. In this case, for example, the researchers assumed that the disease they were modelling had similar pathological effects on men and women, whereas in reality many sexually transmitted diseases affect women more severely than men, potentially changing the effect of the disease on polygynists.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/118336/original/image-20160412-15895-1jiom3e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Promiscuous fellow.</span>
<span class="attribution"><span class="source">Gilles San Martin/wikimedia</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Further questions are raised by research into sexually transmitted diseases in animals, which hasn’t really found a clear relationship between promiscuity and disease. In fact, <a href="http://rspb.royalsocietypublishing.org/content/269/1491/585">computer modelling work focused on animals</a> has found that promiscuous and monogamous individuals can coexist even in the presence of a dangerous disease. What’s more, there are examples of highly promiscuous animals which are heavily infected with sexually transmitted diseases yet carry on regardless (<a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2656.2004.00769.x/full">two-spot ladybirds in Continental Europe</a> are one example, believe it or not).</p>
<p>As the researchers themselves point out, there are indeed some challenges associated with this idea. More detailed simulations or better data on sexually transmitted infections in societies where people live in small groups would make the picture clearer. For now, it remains an intriguing and plausible suggestion that we should explore further. Given the continuing threats posed by sexually transmitted diseases today it’s surprising that it’s taken this long for someone to put two and two together and suggest that the advent of monogamy may have served a very practical purpose.</p><img src="https://counter.theconversation.com/content/57592/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Knell has recieved funding from The Wellcome Trust and the Natural Environment Research Council for research into STIs. </span></em></p>Researchers show that a sexually transmitted disease similar to gonorrhoea could have got rid of promiscuous behaviour in agricultural societies.Rob Knell, Senior Lecturer, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/508502016-02-07T19:06:41Z2016-02-07T19:06:41ZWe need a cure for bacterial vaginosis, one of the great enigmas in women’s health<figure><img src="https://images.theconversation.com/files/110243/original/image-20160204-5826-zpjw2p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bacterial vaginosis affects at least 12% of Australian women.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p><em>This article is part of our series examining hidden women’s conditions. You can also read today’s pieces on why women <a href="http://theconversation.com/why-women-see-their-gp-more-than-men-49051">see their GP</a> more than men; and the need to empower women with <a href="http://theconversation.com/vulvas-periods-and-leaks-women-need-the-right-words-to-seek-help-for-conditions-down-there-53638">appropriate language</a> to seek help when their body “malfunctions”.</em></p>
<p>Few have heard of bacterial vaginosis (BV) although it’s a relatively common condition. It affects at least <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0057688">12% of Australian women</a>, <a href="http://journals.lww.com/greenjournal/Abstract/2007/01000/Prevalence_of_Bacterial_Vaginosis__2001_2004.18.aspx">30% of American women</a> and up to <a href="http://jama.jamanetwork.com/article.aspx?articleid=1157494&resultclick=1">50% in parts of Africa</a>.</p>
<p>Symptoms <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/bacterial-vaginosis">include a watery, milky discharge</a> and fishy odour coming from the vagina. </p>
<p>Women with BV are <a href="http://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm">more likely to get</a> sexually transmitted infections (STIs) – such as chlamydia, gonorrhoea and herpes – and to transmit or acquire HIV. They are more likely to develop pelvic inflammatory disease, a painful condition that can result in infertility. </p>
<p>Pregnant women with BV are <a href="http://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm">more likely to suffer miscarriages</a> and deliver premature and low birth-weight babies.</p>
<p>Studies have shown women’s self-esteem, sexual relationships and quality of life <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074378">suffer significantly</a> from this infection. Women have reported BV symptoms make them feel embarrassed, “dirty” and concerned others may be able to detect their odour.</p>
<p>Many women with BV symptoms think they are <a href="http://medicinetoday.com.au/2004/june/feature-article/vulval-itch-all-itches-not-thrush!">experiencing thrush</a>, and commonly report being treated for this. But BV doesn’t cause itching and there is often a noticeable fishy odour. Improper treatment for this condition leads to persistent symptoms, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0074378">frustration and distress</a>.</p>
<h2>Why BV is hard to treat</h2>
<p>Bacterial vaginosis is caused by groups of bacteria. This makes it different from other genital infections, such as chlamydia and gonorrhoea, where one bacterium is responsible. </p>
<p>While the cause of BV remains the subject of ongoing research, we do know there is a marked <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa043802">disruption of the vaginal bacterial community</a> in women with BV compared to those with a healthy vaginal state.</p>
<p>BV is associated with a <a href="http://www.sciencedirect.com/science/article/pii/S0002937801772353">decreased number of good bacteria</a>, known as lactobacilli, and an increase in bad bacteria. Lactobacilli dominate the healthy vagina, fighting bad bacteria and other other disease-causing agents.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/110070/original/image-20160203-6936-lv0lo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">BV is associated with a decrease in good bacteria in the vagina, and increase in bad.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Latest research into the bacterial profile of the vagina has suggested that as well as this imbalance, women with BV have a <a href="http://journals.lww.com/greenjournal/Abstract/2005/11000/Adherent_Biofilms_in_Bacterial_Vaginosis.19.aspx">bacterial biofilm</a> on their vaginal wall.</p>
<p>This is a kind of network and scaffolding of bacteria that cause cells to stick to each other. The biofilm blocks the body’s defence mechanisms and <a href="http://www.sciencedirect.com/science/article/pii/S0002937807008150">protects bacteria against antibiotics</a> which have difficulty penetrating the biofilm.</p>
<p>Current <a href="http://reproduct-endo.com/article/view/55214">treatment guidelines</a> include seven days of either oral antibiotic tablets or the insertion of a vaginal antibiotic cream for seven nights. </p>
<p>These antibiotics have 80% to 90% cure rates one month after treatment. But more than half of treated women get BV back again <a href="http://jid.oxfordjournals.org/content/193/11/1478.short">within six months</a>. </p>
<p>No other <a href="http://www.ncbi.nlm.nih.gov/pubmed/16647911">treatment approaches</a> (longer antibiotic regimens, combinations of different antibiotics or supplementing <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0034540">antibiotics with probiotics</a> to try and restore the healthy vaginal bacterial balance) have resulted in a sustained, long-term cure. </p>
<p>This is likely due to the bugs causing BV persisting after treatment or because women are being reinfected by their partners.</p>
<h2>Sexual transmission</h2>
<p>Trials between 1985 and 1997, where males were treated alongside their female partners, didn’t consistently reduce BV recurrence rates. These trials <a href="http://journals.lww.com/stdjournal/Abstract/2012/10000/Systematic_Review_of_Randomized_Trials_of.15.aspx">have since been shown</a> as flawed and inconclusive.</p>
<p>Now there is mounting evidence to suggest sex is strongly linked with the acquisition of BV and its recurrence in treated women.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109305/original/image-20160127-19637-1235nk1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">There is mounting evidence of sexual transmission.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/oid-w/7750998534/in/photolist-cNVTPL-fPf9X7-qpAQ1-yMPWCm-MMM9b-tAET4-cKreAJ-cLB82J-cMGJMG-bP9DE-MNc1x-9abtXG-8oNQQ-cVPFvd-7DAGSL-8BpXwP-afYnY5-4GXQSh-fnBkq-7R9upo-4GTFjt-4GXQZ7-o4qu2-5Pu7UN-afpKdW-3aUFQd-qpAKC-5nXoWh-efhMWd-9abtXL-MMNWA-MNfTx-MMUjZ-MN4Uq-MN8Mk-a3oDt6-qpAPH-daxfRf-qpAQu-4dQK6t-qpAL7-9abtXJ-7xzam-8DRiTY-75fdpB-6Pje4q-j9Zrd-2VoeKM-bfj35r-9aJe12">Miles Cave/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Studies have found women with male sexual partners who <a href="http://cid.oxfordjournals.org/content/47/11/1426.short">didn’t use condoms were consistently</a> more likely to have BV. And women who have been treated and then <a href="http://cid.oxfordjournals.org/content/56/6/777.short">re-exposed to the same partner</a> were more likely to get their BV back. </p>
<p>Studies exploring bacterial communities on the penis have found <a href="http://mbio.asm.org/content/6/3/e00589-15.full">BV-linked bugs</a> under the foreskin and at the end of the urine tube. These were more common in men whose partners had BV than in those whose partners didn’t.</p>
<p>In African trials, female partners of <a href="http://www.sciencedirect.com/science/article/pii/S0140673607603134">circumcised males were found to have less BV</a> than those of uncircumcised males.</p>
<p>Despite men not having associated symptoms, the data support the hypothesis that in treated women, sex with an untreated partner may be re-introducing the BV bugs responsible for high recurrence rates.</p>
<p>Other <a href="http://cid.oxfordjournals.org/content/60/7/1042.short">studies have shown women</a> with female sexual partners were more likely to develop BV if they had more partners or a partner with BV. </p>
<h2>We need a cure</h2>
<p>The current state of BV treatment is unacceptable. Despite mounting evidence of sexual transmission, treatment of male and female partners of women with BV is not recommended by international <a href="http://www.cdc.gov/std/tg2015/references.htm#595">guidelines</a>, based on the trials two decades ago.</p>
<p>There are few conditions where doctors know that more than 50% of patients will be back with symptoms within six months. This characteristic of BV highlights the importance of finding the cause of high reinfection rates.</p>
<p>Failure to find a single organism responsible for BV and the difficulty in establishing whether BV is sexually transmitted have all been significant barriers to making progress with a cure.</p>
<p>A number of treatment strategies must be explored, include conducting well-designed clinical trials of partner treatment to see if eradicating the bacteria from women and their partners simultaneously (as we do routinely for STIs such as chlamydia) improves the cure rate.</p>
<p>It is quite possible that no single strategy will eliminate BV in all women and that combinations of approaches may be needed; including using antibiotics with biofilm-disrupting agents and partner treatment. </p>
<p>Drugs that <a href="http://cid.oxfordjournals.org/content/early/2015/04/29/cid.civ353.short">disrupt biofilm</a> are highly experimental, but will also be subject to clinical trials over the next few years and may prove essential in the fight to eradicate BV.</p><img src="https://counter.theconversation.com/content/50850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catriona Bradshaw receives funding from The NHMRC</span></em></p><p class="fine-print"><em><span>Lenka Vodstrcil does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Few women have heard of bacterial vaginosis (BV) and often confuse its symptoms with thrush. But improper treatment of BV can lead to persistent symptoms and distress.Lenka Vodstrcil, Research Fellow, Melbourne Sexual Health Centre, Monash UniversityCatriona Bradshaw, Associate Professor, Melbourne School of Population and Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/448662015-07-30T05:16:51Z2015-07-30T05:16:51ZCould HIV-prevention pills actually increase infection risk by cutting condom use?<figure><img src="https://images.theconversation.com/files/89491/original/image-20150723-22811-1qtowp4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>It’s been hailed as a major breakthrough and one of the much-needed tools to “<a href="http://www.theguardian.com/commentisfree/2015/feb/26/hiv-treatment-game-changer-truvada-nhs-trial">end HIV</a>”. But there are <a href="http://betablog.org/re-thinking-risk-compensation-conversation-kim-koester/">also concerns</a> about pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV-negative people to prevent them from becoming infected with the virus. Will people taking PrEP stop using condoms and could this actually lead to an increase in HIV and sexually transmitted infections (STIs)?</p>
<p>PrEP appears to be a highly effective method of reducing risk of HIV transmission. Adding to growing <a href="http://www.cdc.gov/hiv/prevention/research/prep/">international evidence</a>, the <a href="http://www.aidsmap.com/Pre-exposure-prophylaxis-PrEP-stops-86-of-HIV-infections-in-PROUD-study/page/2947319/">Proud trial</a> tested the use of PrEP with gay and bisexual men in England and found a reduction in HIV transmission of 86% amongst men who took PrEP every day. Truvada, the drug used in the Proud trial, is not currently licensed for use as PrEP in the UK. However, as a result of the findings, there has been a <a href="http://www.independent.co.uk/life-style/health-and-families/health-news/make-new-hiv-protection-pill-available-on-the-nhs-say-sexual-health-campaigners-9387332.html">concerted effort</a> by HIV policymakers and community activists to make Truvada available as PrEP on the NHS as soon as possible.</p>
<p>Evidence to date has shown mixed results when it comes to continued condom use with PrEP. The Proud trial, which recruited participants reporting some but not exclusive use of condoms, found the number of people not using condoms remained the same throughout the study. STI rates across both trial arms – the group that received PrEP immediately and the group that had to wait 12 months – also remained similar. Evidence from three locations from the <a href="http://www.aidsmap.com/How-will-people-use-PrEP-iPrEx-users-talk-condoms-pills-anxiety-and-relief/page/2894961/">iPrEX study</a> in the US suggests that, although some younger participants reduced condom use, in most cases PrEP did not reduce condom use but did reduce stress, fear, and guilt.</p>
<p>We need to consider who might be willing to use PrEP. A <a href="http://www.bhiva.org/140404JamieFrankis.aspx">number of surveys</a> with gay and bisexual men in the UK have shown that men reporting lower levels of condom use and who are at higher risk of HIV are interested in PrEP. Introducing PrEP to this group might not necessarily reduce condom use, but could protect against HIV infections where condoms are not already being used. In this way, PrEP could fill a gap in HIV prevention for those individuals who find it difficult, or are unable, to use condoms as their main means of preventing HIV.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90161/original/image-20150729-30862-1b3wme4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tried and tested protection.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Our <a href="http://bmjopen.bmj.com/content/4/11/e005717.full">PrEP research</a> in Scotland with gay and bisexual men, and men and women from migrant African communities, found that concerns about PrEP went beyond condom use. Participants in our qualitative study highlighted anxieties around the immediate and long-term side-effects of PrEP, a lack of trust that PrEP would work, and a belief that they were not at high-enough risk to merit taking a daily pill to prevent HIV. In addition, given that PrEP is not 100% effective, skills amongst participants in calculating risk reduction in relation to PrEP appeared to be mixed and will be an important factor in the effective “real-world” use of PrEP.</p>
<p>But our study also highlighted the fear that others would stop using condoms as a result of PrEP. One man compared the impact of PrEP to “women burning their bras” because he was concerned that other men would stop using condoms and threaten a 30-year history of HIV-prevention based on condom use. This suggests that many people still see condoms as the main HIV-prevention tool and demonstrates the need to engage with these fears and identify how PrEP might fit into, rather than disrupt, existing HIV prevention strategies.</p>
<p>Given the <a href="http://www.independent.co.uk/news/uk/home-news/pride-in-london-nhs-to-come-under-pressure-to-provide-miracle-hiv-prevention-pill-10349303.html">likely introduction</a> of PrEP in the UK in the not-too-distant future, we need to draw on existing evidence to encourage its equitable introduction into health services and access by those most at risk of HIV. There needs to be clear guidance and support for using PrEP in combination with existing HIV-prevention strategies, including condoms. We need to find acceptable, effective and clear ways of explaining PrEP to potential users and work to improve understandings and skills in assessing and reducing risk. </p>
<p>Finally, we need to address existing – and sometimes conflicting – <a href="http://www.aidsmap.com/PrEP-wars-debating-pre-exposure-prophylaxis-in-the-gay-community/page/2572027/">community concerns</a> about PrEP . We need to find ways of talking openly about what a range of HIV prevention options might look like, without moralising or judging individual practices. Good sexual health needs to recognise the dynamic lives of people affected by HIV. No matter how well PrEP might work, it alone will not be the magic bullet to end HIV.</p><img src="https://counter.theconversation.com/content/44866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa McDaid receives funding from the UK Medical Research Council, Scottish Chief Scientist Office and the National Institute for Health Research.</span></em></p><p class="fine-print"><em><span>Ingrid Young holds a fellowship funded by the Scottish Chief Scientist Office (CSO).</span></em></p>PrEP drugs to prevent people contracting HIV mustn’t disrupt existing sexual health strategies.Lisa McDaid, Programme leader, MRC/CSO Social and Public Health Sciences Unit, University of GlasgowIngrid Young, Research fellow, MRC/CSO Social and Public Health Sciences Unit, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/442752015-07-30T05:16:45Z2015-07-30T05:16:45ZHow to get more men using condoms – put the pleasure back into sex<figure><img src="https://images.theconversation.com/files/90150/original/image-20150729-30882-14odzyv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Pleasure, excitement and intimacy are <a href="http://link.springer.com/article/10.1007/s10508-007-9213-0#page-1">powerful drivers</a> in young people’s sexual decision making. But they are rarely considered when it comes to strategies for reducing the risk of sexually transmitted infections (STIs) or promoting condom use.</p>
<p>Stubbornly <a href="http://www.hpa.org.uk/stiannualdatatables">high rates of STIs</a> in the UK, particularly among under-25s, demonstrate that the plethora of <a href="http://www.fpa.org.uk/campaigns/sexual-health-week">messages and campaigns</a> focused on risk of infection as the driver for condom use have failed to resonate with young people. Or more accurately, with all young people, all the time. It is time to move away from building messages around sex as a risk of infection or pregnancy, and instead to develop campaigns around sex as pleasure, intimacy and excitement.</p>
<p>Some <a href="http://thepleasureproject.org/">recent practice</a> <a href="http://jennyhiggins.net/publications/">and research</a> is starting to put the pleasure agenda in the foreground of sexual health. For example, <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302567">recent empirical research</a> in the United States has highlighted how young people’s motivation to seek pleasure was the most important factor behind their lack of condom use. This priority means pleasure is a factor we can’t afford to neglect.</p>
<p>For young men, sex is also pivotal in the construction of their sense of masculinity. <a href="http://search.proquest.com/openview/8bf834a946e0656d72adfcb686deb761/1?pq-origsite=gscholar">Pressures on young men</a> to be good at sex, to take the lead and to maintain and sustain an erection are high. Condom use can threaten or undermine these imperatives by placing this performance at risk. Young men fear that the interruption to apply a condom may cause them to lose their erection and make them appear fumbling and unsure. It requires a level of negotiation and discussion which they can find difficult and embarrassing and it does not fit their conception of sex as spontaneous and exciting.</p>
<p>This combination means that, despite having the knowledge about its importance, condom use in itself constitutes a more immediate and significant risk to young men than that of infection, which is often seen as <a href="https://theconversation.com/have-young-people-stopped-fearing-sexually-transmitted-infections-44341">trivial and treatable</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90153/original/image-20150729-30882-18794y3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">That’s one way to get over the awkwardness.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Embracing and seeking to control risk is a <a href="https://books.google.co.uk/books?hl=en&lr=&id=_FSSAgAAQBAJ&oi=fnd&pg=PP1&dq=Lyng+Edgework&ots=TrXqmE5A2Q&sig=2ud7CoVQCLvt5qRgWORhX82xLag#v=onepage&q=Lyng%20Edgework&f=false">valued masculine attribute</a>. Consequently, being seen as sexually risky and adventurous by rejecting social conformities relating to safe sex can also <a href="http://www.sciencedirect.com/science/article/pii/S027795360500211X">enhance masculine status</a>.</p>
<p>However, it is not only young men who are resistant to condom use. <a href="http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302567">Research shows</a> that young women also have preferences for condom-less heterosexual sex, often citing condoms’ impact on feelings of intimacy and trust as important factors. And while gender stereotypes and masculine expectations mean that this “romantic” rationale is not typically associated with or acknowledged by young men, it doesn’t mean that, in the privacy of an encounter with their partner, the desire to be intimate and the pleasure of this closeness is not also privileged by young men.</p>
<p>Talking more about pleasure would enable us to better promote condom use among young men. It would enable us to explore alternatives to penetrative sex, discuss the nitty gritty (such as how to manage condom use without fumbling and embarrassment) and challenge the preoccupation with sex as a performance to be mastered. </p>
<p>Putting pleasure and excitement at the heart of our discussions with young men provides us with a coherent, inclusive and meaningful starting point from which to talk about sex. It brings policy and interventions alongside the interests of young men rather than in opposition to them and offers a space in which to address the concerns relating to masculinities that trouble them.</p><img src="https://counter.theconversation.com/content/44275/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Eastham receives funding from the ESRC.</span></em></p><p class="fine-print"><em><span>Mark Limmer does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Tackling men’s reluctant condom use comes down to the basics of how they view sex.Mark Limmer, Lecturer, Division of Health Research, Lancaster UniversityRachael Eastham, PhD candidate, Division of Health Research, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/443412015-07-29T10:41:11Z2015-07-29T10:41:11ZHave young people stopped fearing sexually transmitted infections?<figure><img src="https://images.theconversation.com/files/90119/original/image-20150729-30862-1mxj1z2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The good news is that rates of teenage pregnancies are at <a href="http://www.theguardian.com/lifeandstyle/2015/jul/15/teenage-pregnancies-uk-drops-lowest-level-70-years">record lows</a>. In 2014 in England and Wales they were at the <a href="http://www.ons.gov.uk/ons/rel/vsob1/birth-summary-tables--england-and-wales/2014/index.html">lowest rate</a> since 1946, with only 15.6 pregnancies per 1,000 women younger than 20.</p>
<p>Unfortunately, rates of sexually transmitted infections (STIs) are still very high. There were <a href="http://www.ons.gov.uk/ons/rel/vsob1/conception-statistics--england-and-wales/2013/stb-conceptions-in-england-and-wales-2013.html">440,000 diagnoses</a> in the UK in 2014, and the under 25s are one of the most high risk groups. STIs have a high financial cost for testing and treatment: diagnoses of chlamydia alone cost the NHS <a href="http://www.fpa.org.uk/sites/default/files/unprotected-nation-executive-summary.pdf">£620m</a> in 2011.</p>
<p>Condoms provide effective protection against STIs but many people choose not to use them – around <a href="http://bit.ly/2xMf1uD">15% of under-25s</a> reported having unprotected sex with two or more partners in the last year. So why don’t young people use condoms? The most commonly given reason is the impact on <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2496933/">sexual pleasure</a> <a href="http://bit.ly/2xM1cfM">and intimacy</a>. Pleasure is of course a very important part of sex, so anything that is perceived to interfere with it is bound to be viewed negatively.</p>
<h2>Mixed evidence</h2>
<p>Some also argue that young people don’t use condoms because they aren’t scared of <a href="http://www.yourtango.com/2014208790/sexual-health-safe-sex-why-arent-we-afraid-stds-anymore">contracting STIs</a> anymore. Today, the majority of common STIs, including <a href="http://www.nhs.uk/Conditions/Chlamydia/Pages/Treatment.aspx">chlamydia</a> and <a href="http://www.nhs.uk/Conditions/Gonorrhoea/Pages/Treatmentpg.aspx">gonorrhoea</a>, can be cured quickly with antibiotics, while HIV can be managed and those who contract it can expect to <a href="http://www.theguardian.com/global-development/2015/jul/14/people-with-hiv-aids-live-nearly-20-years-longer-than-in-2001">live 20 years longer</a> than was the case in 2000.</p>
<p>While this idea makes sense, the evidence supporting it is mixed. Research has shown people’s <a href="http://journals.lww.com/stdjournal/Abstract/2006/03000/Incidence_of_Sexually_Transmitted_Diseases_and_HIV.13.aspx">beliefs about the seriousness of non-HIV STIs are not</a> related to their behaviour, suggesting that it doesn’t make any difference whether people think STIs are serious or not: they’re still likely to put themselves at risk. This is despite the fact that, if left untreated, they can cause complications such as infertility.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/90124/original/image-20150729-30889-1q58ym2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Joint decision.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Fear of HIV, on the other hand, may well influence behaviour. The problem is that many people may not feel at risk of catching it, particularly non-black-African heterosexual people, who are statistically at <a href="https://www.gov.uk/government/statistics/hiv-data-tables">lower risk of HIV</a>. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22404427">One study</a> showed heterosexual people who were at high risk of STIs and HIV underestimated that risk and many didn’t use condoms. This suggests that young people’s decision to use a condom or not may depend on whether they think they are at risk of an STI rather than how severe they think the consequences are.</p>
<p>We should also be aware that the decision to wear a condom isn’t always made by one person. Their partners may also be involved, and <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2496933/">expectations</a> about their reaction (or a <a href="http://www.ncbi.nlm.nih.gov/pubmed/18725548">lack of discussion</a> altogether) may influence the choice. Getting caught in the “<a href="http://www.researchprotocols.org/2015/3/e82/">heat of the moment</a>” is a commonly cited barrier to condom use and experiments have shown that sexual arousal in men <a href="http://people.duke.edu/%7Edandan/Papers/PI/Heat_of_Moment.pdf">reduces their ability</a> to make decisions. </p>
<h2>Sex-positive approach needed</h2>
<p>So what can we do to change this situation? Previous educational programmes have often focused on the “<a href="http://pps.sagepub.com/content/9/5/455.short">dangers</a>” of unprotected sex. But <a href="http://www.tandfonline.com/doi/abs/10.1080/17437199.2012.703527#.VZu2uflVhBc">evidence suggests</a> that scaring people, in particular those who feel unable to change their behaviour, can just cause them to become defensive.</p>
<p>The fact that perceived loss of sexual pleasure appears to be the fundamental reason most people don’t use condoms highlights how important it is to address the positive aspects of sex, rather than solely focusing on the negative consequences. Finding a way to enhance sexual pleasure with condoms, or at least change beliefs about pleasure, is important. This could be as simple as improving actual sensation with condoms, from recommending thinner designs to revolutionary new materials such as <a href="http://www.newscientist.com/article/mg22429920.400-the-futures-flat-the-wondrous-world-of-2d-materials.html#.VZu6QPlVhBc">graphene</a>. Alternatively, it could involve persuading people that <a href="http://www.researchprotocols.org/2015/3/e82/">safe sex can be good sex</a>. </p>
<p>This sex-positive approach attempts to target an important driver of behaviour: motivation. We are primarily driven by our <a href="http://www.primetheory.com/">wants and needs</a> in any particular moment. Therefore, we need to make people want to use condoms, rather than making them feel that they should. To do this, we should focus on outcomes that are <a href="https://books.google.co.uk/books?hl=en&lr=&id=CoGNDeVdjoQC&oi=fnd&pg=PR1&dq=Self-Regulation+in+Health+Behavior&ots=ZpIV0qGSb2&sig=ZWdPGvVBnJL0bztN8z5a8cNQH6E#v=onepage&q&f=false">important to people</a> –- things that we know they want.</p>
<p>For example, when targeting smoking, focusing on appearance-related consequences may be more effective than focusing on health-related consequences, for people who value being attractive. Interventions to increase condom use should therefore focus on more immediate goals that young people care about, such as enjoying good sex or gaining social approval.</p>
<p>We certainly haven’t cracked the problem of getting people to use condoms yet. However, focusing on goals that are important to young people create an exciting new area for future investigation.</p><img src="https://counter.theconversation.com/content/44341/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rosie Webster receives funding from UK National Institute for Health Research, Health Technology Assessment Program, 10/131/01.
Views are entirely of the author and do not reflect the views of the funder or of UCL eHealth unit.</span></em></p>STIs might be easier to treat or manage but unprotected sex still comes with potentially serious risks.Rosie Webster, Research Associate in Digital Health and Sexual Health, UCLLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/449862015-07-28T20:06:52Z2015-07-28T20:06:52ZLet’s talk about sex over 60: condoms, casual partners and the ageing body<figure><img src="https://images.theconversation.com/files/89885/original/image-20150728-7665-1crqcmz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-19730155/stock-photo-happy-senior-adult-couple-kissing.html?src=iuJk2rIBZnXwZ3yXytVmZg-3-123">Andy Dean Photography/Shutterstock</a></span></figcaption></figure><p>Over the past few years we’ve seen a dramatic rise in the rates of sexually transmitted infections (STIs) among Australians aged 60 years and older. Rates of gonorrhoea <a href="http://kirby.unsw.edu.au/surveillance/2012-annual-surveillance-report-hiv-viral-hepatitis-stis">more than doubled</a> in this age group between 2007 and 2011. Rates of chlamydia also rose significantly during this time, mirroring similar <a href="http://sti.bmj.com/content/early/2008/06/27/sti.2007.027847.full.pdf">trends internationally</a>.</p>
<p>STIs can be accompanied by some <a href="http://www.sciencedirect.com/science/article/pii/S0378512210002100">unpleasant symptoms</a> and health complications, or lead to major chronic conditions, in the case of HIV. It’s therefore important STIs are diagnosed and treated, regardless of age. </p>
<p>To understand why STIs are on the rise, we need to know more about older people’s sexual and romantic relationships, their knowledge of STIs and safe sex, and the safe sex practices that they use. However, older people are routinely <a href="https://theconversation.com/invisible-sexuality-older-adults-missing-in-sexual-health-research-34078">excluded</a>
from research on sex and relationships. Here’s what we know so far. </p>
<h2>Changing sexual and relationship patterns</h2>
<p>The Baby Boomer generation is renowned for challenging norms around <a href="https://theconversation.com/sex-desire-and-pleasure-in-later-life-australian-womens-experiences-35725">sex and age</a> and this has continued in recent decades.</p>
<p>Improvements to life expectancy and overall health in later life mean that older people may be more willing and able to engage in varying kinds of sexual activity. In fact, there is some evidence to suggest that remaining sexually active is associated with <a href="http://link.springer.com/article/10.1007/s12126-011-9110-7">better health in older age</a>.</p>
<p>Changes in the social acceptability of divorce and dating in later life have also opened up the possibility of entering in to a new sexual relationship. With new sexual partners comes an <a href="http://www.maturitas.org/article/S0378-5122(12)00405-7/abstract?rss=yes">increased possibility</a> of contracting an STI. </p>
<p>Alongside this, internet dating has increased the opportunities to meet <a href="http://apo.org.au/research/love-actually-older-adults-and-their-romantic-internet-relationships-0">new sexual or romantic partners</a>. And medical advances such as Viagra have made (penetrative) sex in later life more of a possibility for older men than was previously the case.</p>
<p>However, this does not mean that all older people are sexually active, or that they are sexually active in the same ways as younger people. Instead, <a href="http://www.tandfonline.com/doi/full/10.1080/14681994.2014.936722#abstract">research suggests</a> that older people engage in a diverse range of sexual practices, and may have to adjust to ageing bodies. </p>
<h2>Let’s (not) talk about sex</h2>
<p>Despite these changes, and increasing <a href="https://theconversation.com/britons-have-sex-sooner-older-but-less-often-20735">evidence</a> that older people continue to be sexually active, there’s a reluctance to acknowledge this shift. Many in the community continue to cling to outdated and ageist assumptions that older people are asexual.</p>
<p>As a result, medical professionals can be reluctant to talk to their older patients about sex. <a href="http://www.sciencedirect.com/science/article/pii/S0277953603004490">Research in the United Kingdom</a>
shows GPs assume the topic of sexual health is not relevant to older people, and fail to proactively raise this issue with their older patients. This is often based on an <a href="https://theconversation.com/a-ripe-old-age-the-joy-of-sex-later-in-life-just-dont-forget-the-condoms-1969">incorrect assumption</a> that older people are no longer sexual.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=298&fit=crop&dpr=1 600w, https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=298&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=298&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=375&fit=crop&dpr=1 754w, https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=375&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/89888/original/image-20150728-7668-191s5jk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=375&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How do you negotiate condom use and an ageing body?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-298213292/stock-photo-two-open-condoms-and-sealed-condoms.html?src=otN1pL8KgmCMUv71EspmGg-2-20">Studio KIWI/Shutterstock</a></span>
</figcaption>
</figure>
<p>This reluctance can have direct and negative implications for the sexual health of older people. It becomes less likely that older patients will be offered <a href="https://theconversation.com/health-check-the-sti-check-up-warts-and-all-32160">routine sexual health screenings</a>
, or have the opportunity to ask their GP questions about sexual health.</p>
<h2>Learning about safe sex is a life-long endeavour</h2>
<p>When we talk about safe sex and STIs, our focus tends to be on <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1741-6612.2008.00336.x/full">younger people</a>. In some ways this makes sense: many younger people are entering their first sexual relationships and need to learn how to have sex safely. </p>
<p>There is also an assumption that older people already know about safe sex. Yet, many older people grew up in a time when comprehensive sex education wasn’t provided in school. For those who have been in long-term, monogamous relationships, using condoms may have seemed irrelevant.</p>
<p>Older Australians need different types of information at different stages in the life course. Those reentering the dating or casual sex scenes, for instance, might benefit from a refresher on safe sex. </p>
<p>Older people might also have unique or different safe sex needs to their younger counterparts. For example, how does one negotiate condom use and an ageing body? How can issues around increased friction and pain that can be associated with condom use (particularly for postmenopausal women) be managed? </p>
<p>We need age-specific education and resources.</p>
<h2>Don’t delay treatment</h2>
<p>STIs can be costly to treat, and the economic burden of STIs increases with delayed diagnosis and treatment. Delayed treatment can result in more <a href="http://link.springer.com/article/10.1007/s11908-006-0010-z">severe symptoms</a> and <a href="http://www.sciencedirect.com/science/article/pii/S0197457211003363">complications</a>. Ignoring older people as sexual beings may contribute towards poorer overall health and deny their sexual agency.</p>
<p>We need to be more proactive in engaging older Australians around their sexual health. This could start with providing education, access to testing, and opportunities for discussions about sex, relationships, and sexual health. </p>
<p>We also need to know more about sex and relationships among older Australians and what they already know or don’t know about STIs and safe sex. This week we launched <a href="http://sexagemesurvey.org.au">SexAge&Me</a>, the first national study of older Australians’ sexual and romantic relationships, to help answer these questions and inform future approaches to sexual health policy and health care responses. </p>
<p><em>If you’re an Australian resident aged over 60 and want to take part in the survey, <a href="http://www.demographix.com/surveys/N5FZ-LWS6/8XQ4JKG3/">click here</a>.</em></p><img src="https://counter.theconversation.com/content/44986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bianca Fileborn receives funding from the Australian Research Council to undertake research on STIs and ageing.</span></em></p><p class="fine-print"><em><span>Anthony Lyons receives funding from the Australian Research Council to undertake research on the sexual health of older Australians. </span></em></p>Over the past few years we’ve seen a dramatic rise in the rates of sexually transmitted infections (STIs) among Australians aged 60 years and older.Bianca Fileborn, Research Officer at the Australian Research Centre for Sex, Health & Society, La Trobe UniversityAnthony Lyons, Senior Research Fellow, Australian Research Centre in Sex, Health and Society, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/445972015-07-16T19:29:14Z2015-07-16T19:29:14ZNorthern Australia syphilis outbreak is about government neglect, not child abuse<figure><img src="https://images.theconversation.com/files/88624/original/image-20150716-5089-6swco6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Syphilis outbreaks tend to occur in marginalised populations where there is a lack of affordable, appropriate and culturally acceptable health care.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/barkochre/251902177/in/photolist-og4JZ-8vqDsw-2fNt7j-8vqBMG-4WSQh7-48CoBM-89pxEr-8vnzLt-4vaApc-7ftPxg-8txe3a-2e8zVU-9kkH4p-fcgQvz-4Hj3nA-DgDTk-7eJZ2v-fySHVY-g8iTu3-2h3bX5-7WbEhf-4rL3MY-4rSvo4-ama5St-ah434f-5jgr9p-4SMCTZ-qLKpf">yaruman5/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>The <a href="http://www.abc.net.au/news/2015-07-12/syphilis-outbreak-nt-indigenous-youth-prompts-fears-for-unborn/6613514">recent syphilis outbreak</a> in Central Australia highlights the urgent need for investment in sexual health services for young Aboriginal Australians living in remote regions.</p>
<p>Since July last year, 134 cases of the sexually transmitted disease have been reported in the Barkly and Katherine regions. This is up from 15 reported cases in the 2013-14 financial year. </p>
<p>There’s a serious risk the outbreak will extend into other parts of remote Australia. But suggestions that the recent rise in syphilis cases has something to do with child sexual abuse in Aboriginal communities are an irresponsible distraction from the issue at hand. </p>
<p>What both the territory and federal governments need to do is acknowledge that investment in primary health-care delivery in remote Aboriginal communities is inadequate. That’s why outbreaks of sexually transmitted diseases are confined to these regions, while being a rarity in mainstream Australia.</p>
<p>Globally, syphilis outbreaks have been reported in many <a href="http://khn.org/morning-breakout/dr00002167/">marginalised populations</a>, including <a href="http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5906a2.htm">Native Americans,</a> <a href="http://gov.nu.ca/health/information/syphilis-outbreak-nunavut">First Nations</a> peoples and African Americans. All these groups share a common problem: lack of access to affordable, appropriate and culturally acceptable health care.</p>
<h2>Outbreaks of syphilis</h2>
<p>Syphilis is a sexually transmitted bacterial infection. In Australia, it mainly affects urban gay men and heterosexual people in remote Aboriginal communities. It’s extremely uncommon in the general population. </p>
<p>The <a href="http://www.sti.guidelines.org.au/sexually-transmissible-infections/syphilis#clinical-presentation">symptoms are often mild and transient</a>, making it easy for infectious people to unknowingly transmit the infection to their sexual partners. But if left untreated, syphilis can affect multiple organs, including the heart, brain, bones and joints.</p>
<p>Most concerning is that the infection <a href="http://www.health.vic.gov.au/neonatalhandbook/infections/syphilis.htm">crosses the placenta</a>, which accounts for high rates of stillbirth or permanent disabilities in children, including blindness and even perinatal death.</p>
<p>Exactly why syphilis outbreaks occur is not fully understood. Until recently <a href="http://www.nature.com/nature/links/050127/050127-1.html">the prevailing theory</a> was that due to acquired partial immunity in the population, syphilis rates fluctuate naturally in cycles of about ten years. But more recent evidence has discounted this theory and suggested changes in sexual behaviour and the vigour of <a href="http://precedings.nature.com/documents/1373/version/1">public health control programs</a> are the main factors driving syphilis rates at the population level.</p>
<p>Another factor - and one that plays into the current outbreak - is the recent realisation that <a href="http://aac.asm.org/content/54/2/583.full">syphilis is becoming resistant to common antibiotics</a> such as azithromycin, which is used widely to treat other infections. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/88641/original/image-20150716-5108-1esrz9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sexual behaviours of Aboriginal young people are broadly the same as those of other young Australians.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/thomashawk/211626852/in/photolist-7nh9ar-nRLt3t-9nf73B-5rCNrP-avg5ks-7nhQbV-8KDJvT-gQbdwt-pvnJb7-8CY6xV-8AJXMC-8PHh2Z-f6hTM5-edcjfR-8xnMuU-gxA95-aEiAVv-3N1wYY-8wRTrV-8ByV3k-gLpBpo-jGDhQ-9hvFDL-7EGLC-acUNrr-e2rqeM-8Sod4U-7nmnYy-4MCW82-3i22L-mJXr9j-qKy8Wh-4PgEvk-qrwYuv-gxzyn-ehW3ha-gvRRsj-aAua5C-oXk9pc-4UJqk8-7DHPQT-dHMKrW-jVW2AF-kaU8m7-72DcVz-y8n2D-6JegTp-78P1zb-78P2Lo-5dW9i">Thomas Hawk/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Syphilis in children</h2>
<p>Syphilis is a notifiable disease, which means that doctors who make a diagnosis have a legal obligation to report the case to their jurisdictional health department. The majority of the current outbreak’s notified syphilis cases have been among Indigenous people aged 15 to 19. But the disease has affected children as young as 12. </p>
<p>The legal age of sexual consent in the Territory, and many other jurisdictions, is 16. But the median age of sexual debut in Australia is 15. This is the same everywhere - in mainstream Australia and among Aboriginal people in the Northern Territory.</p>
<p>Indeed, <a href="https://www.sahmri.com/our-research/themes/infection-immunity/research/list/sexual-health-and-relationships-survey-2">survey data has shown</a> that the sexual behaviours of Aboriginal young people in the Northern Territory and other remote areas are broadly the same as those of other young Australians. There are similar numbers of sexual partners, for instance, and similar rates of condom use, as well as same-aged sexual partners. </p>
<p>Of course, sexually transmitted infections in children are a major concern. But it’s important to remember that most sexually transmitted infections in the Northern Territory in adolescents below the age of 16 (that is, below the age of consent) occur among 14 and 15-year-olds. And these rates are <a href="http://kirby.unsw.edu.au/surveillance/2014-aboriginal-surveillance-report-hiv-viral-hepatitis-stis">similar to non-Indigenous young Australians</a>. These notifications – both in mainstream and Aboriginal Australia - predominantly arise because of early sexual debut.</p>
<p>In recent days, the Northern Territory’s health minister, John Elferink, <a href="http://www.abc.net.au/news/2015-07-12/syphilis-outbreak-nt-indigenous-youth-prompts-fears-for-unborn/6613514">has alluded</a> to the increasing rates of syphilis being caused by sexual abuse in Territory communities. However well-intentioned, comments linking high rates of sexually transmissible infections among children to child sexual abuse carries a risk of further pushing young people away from services we so desperately need them to engage with.</p>
<h2>Successful programs</h2>
<p>Outbreaks of sexually transmitted infections like this one are related to the inappropriately low level of investment in sexual health in remote areas. They highlight the lack of high-quality education, primary health care and specialist outreach programs, all of which could stop these high rates of infections. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/22697136">Several programs</a> have been successful in bringing rates under control through consistent delivery of primary care, appropriate sexual health education and specific testing and treatment programs. But not all Aboriginal people living in remote areas have access to these programs. </p>
<p>To deal appropriately with the current outbreak, we are using what we have learnt from <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870166/">past syphilis outbreaks</a> and have instigated an intense and sustained public health response. More specifically, we are <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-song-syphilis.htm">focusing on raising awareness</a> of the issue among people at risk, increasing the rate of condom use, and ensuring both early detection and treatment of people infected, as well as their sexual partners, occurs in a timely manner. </p>
<p>What’s urgently required in remote Australia is a significant investment in sexual health to be integrated into existing primary health care services, alongside education.</p>
<p>We need to ensure that young Aboriginal Australians’ sexual debut is a positive and pleasurable experience - not an embarrassing, shameful one because it went hand-in-hand with a sexually transmitted infection.</p>
<p><em>Ms Amanda Sibosado, Sexual Health Coordinator at Kimberley Aboriginal Medical Services, co-authored this article.</em></p>
<p><em>This article was originally published with the headline “Northern Territory syphilis outbreak is about medical neglect, not child abuse”. It has been amended at the authors’ request.</em></p><img src="https://counter.theconversation.com/content/44597/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The syphilis outbreak in Central Australia is not about child abuse. But it highlights the urgent need for investment in sexual health services for Aboriginal Australians living in remote areas.James Ward, Associate Professor, Infectious Diseases Research Aboriginal and Torres Strait Islander Health, South Australian Health & Medical Research InstituteDonna B Mak, Professor, Head of Population and Preventive Health, University of Notre Dame AustraliaJohanna Dups, Masters of Applied Epidemiology (MAE) Scholar, National Centre for Epidemiology and Population Health, Australian National Univeristy (ANU), Australian National UniversityNathan Ryder, Conjoint Senior Lecturer, School of Medicine and Public Health, University of NewcastleLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/351222014-12-08T05:58:35Z2014-12-08T05:58:35ZSyphilis sailed the ocean blue: why a bent femur won’t overturn Columbus theory<figure><img src="https://images.theconversation.com/files/66423/original/image-20141205-8651-yf22sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">So what have we got?</span> <span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/Christopher_Columbus#mediaviewer/File:Landing_of_Columbus_%282%29.jpg">Davepape/Painting by John Vanderlyn</a></span></figcaption></figure><p>In 1495 a horrific new disease appeared in Europe. Acquired by sexual contact and initially spread through Europe by mercenary soldiers from the army of King Charles VIII of France returning from a successful invasion of Italy, this new disease was extraordinarily unpleasant. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1810019/">Commentators at the time described</a> dark green “boils that stood out like acorns,” accompanied by a stench so vile that if you smelt it you would imagine yourself infected, and by pains so severe that it was “as if the sick had laid upon a fire”.</p>
<p>This new disease went by a variety of names, including The Great Pox, but most people preferred to blame it on the neighbours: the British called it the “French disease,” the French called it the “Italian” or “Neapolitan disease” and the Italians called it the “Spanish disease”. Today it is more widely known now as <a href="http://www.nhs.uk/conditions/Syphilis/Pages/Introduction.aspx">syphilis</a>, an infection caused by the <em>Treponema pallidum</em> bacteria. </p>
<p>The most widely accepted theory is that syphilis was brought to Europe from the New World following Columbus’s voyage in 1492. But ideas about the origin of the infection still cause controversy. Most recent <a href="http://www.dailymail.co.uk/health/article-2860447/Did-Christopher-Columbus-bring-syphilis-Europe-Croatian-skeleton-disproves-theory-sexually-transmitted-disease-arrived-aboard-explorer-s-ship.html">is the claim</a> that bones found in Croatia that appear to show signs of syphilitic infection and which pre-date Columbus’ expedition suggest the disease was around since Roman times. But a look at the wider evidence we have suggests otherwise. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=513&fit=crop&dpr=1 754w, https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=513&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/66424/original/image-20141205-8664-6qbpz4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=513&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In 1492, Columbus sailed the oceans blue. And brought back syphilis.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-234534616/stock-photo-discovery-of-america-the-caravels-that-christopher-columbus-set-out-on-his-expedition.html?src=YwDhsw4IZ-HihOXNwd5F7g-1-6">Columbus by Shutterstock</a></span>
</figcaption>
</figure>
<h2>A surprising evolution</h2>
<p>There are four possible explanations as to where the Great Pox originated: that it was always <a href="http://books.google.co.uk/books?id=DfKTAgAAQBAJ&pg=PA4&lpg=PA4&dq=Pestilence+in+Medieval+and+Early+Modern+English+Literature&source=bl&ots=pXXbslWRIM&sig=NyotkqPlohbWsQwrn3yG4u7BDwE&hl=en&sa=X&ei=dOWBVMfiOsu9UZCVgugP&ved=0CDoQ6AEwAw#v=onepage&q&f=false">present in Europe but misdiagnosed</a> as something like leprosy before 1495; it evolved from a less virulent disease that wasn’t transmitted through sex; or it was <a href="http://antimicrobe.org/h04c.files/history/CID-Rothschild-Hx%20of%20Syphilis-2005.pdf">introduced from Africa</a>. The Columbus theory, however, is the most convincing.</p>
<p>Significant evidence in its favour has been building up, especially over the last few years. <a href="http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000148">An important 2008 study</a> of the DNA sequence of the bacterium that causes syphilis – and the sequences of its close relatives – pointed to an origin in the Americas several thousand years ago. <a href="http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000575">A second study</a> using DNA sequence and palaeo-pathological material also pointed to a New World origin sometime between 16,000 and 5,000 years ago.</p>
<h2>Rampage through Europe</h2>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=856&fit=crop&dpr=1 600w, https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=856&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=856&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1076&fit=crop&dpr=1 754w, https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1076&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/66426/original/image-20141205-8664-1x1p4vd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1076&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Earliest known medical illustration of syphilis, Vienna, 1498.</span>
<span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/Syphilis#mediaviewer/File:400Behandlung_der_Syphilis.jpg">Wuselig</a></span>
</figcaption>
</figure>
<p>Remarkably, following its initial rampage through Renaissance Europe the disease seems to have evolved into a somewhat less virulent (although still very severe) disease, and by the middle of the 16th century some commentators were (wrongly) predicting that the disease would soon dissipate entirely. Others, perhaps with more of an eye on their own health, bemoaned the fact that because the boils and the stench had become so rare it was hard to tell who was infected and who wasn’t.</p>
<p>This surprising evolutionary change in the virulence of syphilis is consistent with it being introduced to <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1810019/">a naive and unprotected host population</a> in 1495. If the disease had been evolving to overcome the immune defences of people in the New World for a few thousand years, and the people in the New World had simultaneously been evolving better immune responses, then when the disease suddenly found itself infecting Europeans with no such defences it explains why it appeared to spread like wildfire – with such eye-watering symptoms. </p>
<p>The rapid decline in virulence after the initial rampage is likely to have happened because the main route of spread is through sexual contact, meaning that strains of the disease that didn’t cause a vile smell and giant green pustules would have had a much better chance of transmission and supplanted the original highly virulent strains in short order.</p>
<h2>Third line of investigation</h2>
<p>If the DNA evidence and other more circumstantial arguments about the evolution of virulence are all consistent with a New World origin of the disease, why is there still controversy? There is in fact a third line of evidence available about the origins of syphilis: the damage it sometimes causes to the bones of infected people. We can often see this in archaeological material: the bones of the skull have characteristic pitting, and long bones can also be pitted and deformed. </p>
<p>Every few years, it seems, someone finds a skeleton from an earlier period somewhere in Europe that seems to have syphilitic changes, and we get a new story in the news claiming that syphilis must have been present in Europe before Columbus. There is the well-known <a href="http://www.bbc.co.uk/news/world-europe-11952322">pair of twins from Pompeii</a>, and more recently the skeleton found in Split, Croatia, which has a deformed femur. If these were unquestionably syphilitic changes they would indeed challenge the Columbian hypothesis – but how easy is it to distinguish syphilis from other skeletal pathology?</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=565&fit=crop&dpr=1 600w, https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=565&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=565&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=710&fit=crop&dpr=1 754w, https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=710&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/66427/original/image-20141205-8651-p1374z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=710&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Treponema pallidum.</span>
<span class="attribution"><a class="source" href="http://en.wikipedia.org/wiki/Syphilis#mediaviewer/File:Treponema_pallidum.jpg">CDC/David Cox</a></span>
</figcaption>
</figure>
<p>One part of the problem is that other diseases caused by the bacteria closely related to <em>T. pallidum</em>, <a href="http://www.merckmanuals.com/home/infections/bacterial_infections/bejel_yaws_and_pinta.html">such as Bejel and Yaws</a>, can also cause similar changes and it is extremely hard to distinguish between them. A <a href="http://www.ncbi.nlm.nih.gov/pubmed/22101689">review of all of the claims</a> for changes caused by the treponema bacterium in pre-Columbian skeletal material from Europe found no cases that could conclusively disprove the hypothesis – either the claims of treponemal changes were not well supported, or the dating of the material was questionable. In the case of the latest skeleton from Split, it seems that <a href="http://www.ncbi.nlm.nih.gov/pubmed/25187322">only the femur was affected</a>. I’m no expert on palaeo-pathology but <a href="http://www.dailymail.co.uk/health/article-2860447/Did-Christopher-Columbus-bring-syphilis-Europe-Croatian-skeleton-disproves-theory-sexually-transmitted-disease-arrived-aboard-explorer-s-ship.html">several commentators have suggested</a> that the femur could well have been affected by a disease <a href="http://www.mayoclinic.org/diseases-conditions/fibrous-dysplasia/basics/definition/con-20032196">called fibrous dysplasia</a> rather than syphilis.</p>
<h2>A deadly exchange</h2>
<p>We all know that when Europeans arrived in the New World after 1492 they <a href="http://www.newscientist.com/article/mg13618424.700-how-columbus-sickened-the-new-world-why-were-native-americans-so-vulnerable-to-the-diseases-european-settlers-brought-with-them.html">took many horrific diseases with them</a>, and that infections like measles and smallpox killed huge numbers of native Americans. Some people seem to find it hard to cope with the idea that maybe some diseases also came back across the Atlantic, despite all the good evidence that suggests this is the case. </p>
<p>Looking to the pre-Columbian New World there is extensive evidence from many skeletons, which contrasts with the occasional claims of individual syphilitic-like bones from pre-Columbian Europe. Given the molecular and other evidence supporting the Columbian hypothesis, it will take more than a bent femur to overturn it.</p><img src="https://counter.theconversation.com/content/35122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rob Knell does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In 1495 a horrific new disease appeared in Europe. Acquired by sexual contact and initially spread through Europe by mercenary soldiers from the army of King Charles VIII of France returning from a successful…Rob Knell, Senior Lecturer, Queen Mary University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/346202014-11-25T06:23:13Z2014-11-25T06:23:13ZRumours of the demise of HIV have been greatly exaggerated<figure><img src="https://images.theconversation.com/files/65388/original/image-20141124-19604-18igbhp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Have we really turned the corner over HIV/AIDS?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&searchterm=HIV&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=157667423">Africa Studio</a></span></figcaption></figure><p>Two years ago, the “beginning of the end” of AIDS <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1207138">was announced</a>. It included the promise of reducing HIV transmission by reducing the amount of infectious virus in the population. This relies on a two-pronged approach: giving the same preventative drugs to both positive and at-risk people and regularly testing those at most risk. </p>
<p>The logic around the drugs part of this strategy goes like this. It is <a href="http://www.catie.ca/en/catienews/2014-04-10/insight-hiv-transmission-risk-when-viral-load-undetectable-and-no-condom-used">becoming clear that</a> transmission is very unlikely to happen during unprotected sex between someone who is HIV negative and someone who is positive but whose virus is controlled (an <a href="http://www.aidsmap.com/Viral-load/page/1327496/">undetectable viral load</a>, as it is described by medics). So controlling the virus in the HIV positive person is known as the treatment-as-prevention approach. </p>
<p>Equally, for someone who is HIV negative it <a href="http://www.cdc.gov/hiv/prevention/research/prep/">seems that</a> taking a single pill of HIV treatment every day radically reduces the chances of HIV transmission to around the same levels as using condoms (this is known as taking a pre-exposure prophylaxis). Put these two approaches together and you could question whether, from the perspective of HIV prevention alone, there is any point in continuing to use condoms. </p>
<h2>Reality check</h2>
<p>So is this really the beginning of the end of HIV? I don’t think so. According to last week’s <a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf">report from Public Health England</a>, there are nearly 108,000 people in the UK living with HIV. This is an increase of over 5,000 year on year, though the rate of new diagnoses has been steadily falling among the population as a whole for nearly a decade. </p>
<p><strong>UK HIV/AIDS rates 1981-2013</strong> </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=387&fit=crop&dpr=1 600w, https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=387&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=387&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=486&fit=crop&dpr=1 754w, https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=486&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/65361/original/image-20141124-19639-1sm4hbw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=486&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf">Public Health England Nov 2014</a></span>
</figcaption>
</figure>
<p>But among gay men who are considered most at risk from infection, the 3,250 that were diagnosed in 2013 was the highest ever in a trend that has remained fairly constant for the last few years. It is estimated that 7,200 gay men living with HIV are undiagnosed. They are thought to be the key population which maintains the rate of new HIV infections. </p>
<p>Many of these men have been recently infected and are highly infectious – yet simultaneously they may have clear and rationale beliefs that they are HIV negative (based on previous test results). It is <a href="http://www.theguardian.com/society/2011/nov/29/uk-hiv-testing">estimated that</a> each prevented HIV infection would save between £280,000 and £360,000 in lifetime treatment costs – so targeting this group and enabling them to seek testing and treatment represents a vital way forwards in controlling HIV in the UK and beyond</p>
<h2>The testing conundrum</h2>
<p>What this does is to underline the importance of the second prong of modern HIV prevention. HIV negative and positive people taking drugs is only viable if there is also a high level of regular HIV testing. This would ensure those who are potentially the most infectious (the 7,200 undiagnosed gay men) are quickly accessing the full barrage of HIV treatments and are also out of the infectious pool of people who maintain the steady rates of new HIV infections. </p>
<p>Equally, HIV negative gay men using pre-exposure prophylaxis and engaging in unprotected anal sex must be having regular HIV tests. Otherwise they risk adding to the 7,200 themselves. And because people taking pre-exposure prophylaxis are not receiving the full combination of antiretrovirals, they will rapidly develop resistance to the drugs they are taking. This will undermine their treatment options in future. </p>
<p>It doesn’t help that the current UK guidelines concerning regularity of testing are not consistent. Some recommend annual testing while others recommend more regular testing for those most at risk (every three months in Scotland, for example). Yet definitions of what exactly consistutes being ‘most at risk’ are currently lacking. Viable definitions could include a combination of measures of unprotected sex, a lack of recent HIV testing, recent sexually transmitted infections and psychological measures of vulnerability. </p>
<p>Neither is getting the right people to seek regular HIV tests an easy matter. Over the past decade there have been huge changes in HIV testing behaviour among gay men. Yet the proportion who test regularly still remains low. In a <a href="http://www.gaycon.org.uk/presentations/3.1%20Only%20one-fifth%20of%20negative,untested%20higher%20risk%20MSM%20report%20regular%20HIV%20testing-results%20from%20Scotland,%20Wales,%20Northern%20Ireland%20and%20the%20Republic%20of%20Ireland.pdf">recent study</a> of men who have sex with men from Scotland, Northern Ireland, Wales and the Republic of Ireland, we found less than a third of men at high risk of infection had tested within the past six months. With testing rates this low, fulfilling the biomedical dream of an end to AIDS remains fanciful. </p>
<p>There are <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3561706/">enduring barriers</a> to HIV testing. These relate to fear of positive diagnosis, stigmatising beliefs relating to sex with positive people, and aspects of testing services. While new approaches to testing technologies, such as <a href="http://www.sexualhealthnetwork.org.uk/episode-7-aidanpaul/">self-testing</a> or <a href="http://www.haus.org.uk/">self-sampling</a> offer some leverage in reducing clinic-related barriers to testing, they do little or nothing to reduce the psychological and social ones. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/65390/original/image-20141124-19618-mens8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Overcoming the barriers to testing is the challenge.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?searchterm=gay%20sex&keyword_search=1&page=2&thumb_size=mosaic&inline=85157410">meunierd</a></span>
</figcaption>
</figure>
<h2>HIV prevention meets the messy world</h2>
<p>For the current HIV prevention regime of drugs for all and regular testing to really work they have to embed fully in the often very messy social world. They have to accommodate the difference between people’s beliefs about their HIV status and their actual status and the stability and duration of undetectable viral load (this is often only tested twice a year). </p>
<p>They also have to <a href="http://bmjopen.bmj.com/content/4/11/e005717.long">find their place</a> in the range of existing preventions for other sexually transmitted infections. For example preventing HIV by replacing condoms with daily pre-exposure prophylaxis treatment may enable other infections, including drug-resistant gonorrhoea. </p>
<p>So what of the beginning of the end of AIDS? As the rise of antimicrobial resistance highlights, our best infectious disease control will eventually fail – despite evidence of effectiveness – unless we understand and plan for its translation within complex and adaptive systems. People take up technologies and use them in unanticipated ways. Cultures develop resistance in the same way that bacteria do. We will only ever approach the beginning of the end of AIDS if and when we bear these things in mind.</p><img src="https://counter.theconversation.com/content/34620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Flowers is a Trustee of the National AIDS Trust -the UK's leading charity dedicated to transforming society's response to HIV (although his opinions here as his own). He has received funding from the Economic and Social Research Council, the National Institute for Health Research, the Australian Research Council and several NHS Health Boards.</span></em></p>Two years ago, the “beginning of the end” of AIDS was announced. It included the promise of reducing HIV transmission by reducing the amount of infectious virus in the population. This relies on a two-pronged…Paul Flowers, Professor of Sexual Health Psychology, Glasgow Caledonian UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/232042014-03-04T14:53:23Z2014-03-04T14:53:23ZIn the age of Grindr, HIV support needs to get online<figure><img src="https://images.theconversation.com/files/42768/original/8m3g622h-1393606076.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If people are talking online, we need to be talking about HIV online too.</span> <span class="attribution"><a class="source" href="http://www.flickr.com/photos/aheram/4129059724/sizes/o/">Jayel Aheram</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Websites and apps such as Grindr and Scruff are booming as a new way for men to meet other men. But the people who seek to inform men about HIV and AIDS are finding they need to think on their feet to keep up with their migration online.</p>
<p>The people who could once be found in bars and clubs are now hidden behind online profiles and are proving difficult to reach. As part of a research project for the Terence Higgins Trust, a research team I’m part of at the University of Sussex followed one group of outreach workers over the course of the summer in 2013 as they ventured online to provide support, information and advice on HIV to men who have sex with men.</p>
<p>The way in which gay and bisexual men and men who have sex with men (MSM) meet one another has changed radically over the past century, at least in the UK. Legal reforms, equal rights legislation and a growing tolerance (perhaps even acceptance) of male homosexuality has meant the opportunities for meeting in different ways have grown.</p>
<p>In the past, cruising grounds were often the only way to find sexual partners but by the year 2000, more socially acceptable sites of queer congregation had emerged. Gay, bisexual and other men could meet to socialise, hook up and learn from each other in bars, cafes and clubs. </p>
<p>Meting online is the latest evolution, with sites like Grindr and Gaydar offering the chance to socialise in new ways. For the uninitiated, these websites and applications allow users to create a digital profile, upload images of themselves and then use that profile to connect with other users, often for free. Grindr also uses your smartphone’s GPS to identify how far you are away from other users. Gaydar’s website includes a radio station, chat rooms and a host of other features that allow men to communicate with one another. While these services might be considered hook-up sites, they also offer the opportunity to socialise and hang out with other men online. </p>
<p>The huge numbers of people signing up to these sites is an unmissable opportunity for communicating about sexual health. <a href="http://grindr.com/learn-more">Grindr</a> app, for instance, is downloaded around 10,000 times per day. Meanwhile Gaydar, one the UK’s longest running gay websites has <a href="http://www.outrightresearch.com/content/about_overview.aspx">5.2 million registered users</a> worldwide. But a different approach is needed. </p>
<p>The idea of meeting in a bar or club to learn may seem surprising but it has long been an important part of queer congregation. In 1983, the first AIDS deaths were recorded in Britain. At a time when governments across the world struggled to formulate an appropriate response, it was gay men (and their friends) who started to educate one another about HIV, safe sex and condom use. This education didn’t happen in school or at work. It happened on the street, in bars, around the “village” and at the cruising ground. Community outreach has been an <a href="http://www.cdcnpin.org/scripts/hiv/programs.asp">integral part</a> of the battle against HIV/AIDS and this work continues today but now needs to get online.</p>
<p>The outreach workers we monitored found that the sense of anonymity and distance created by the computer screen provided an environment in which men could talk honestly about their worries and concerns. This in turn allowed workers to offer the most relevant and appropriate advice to their clients and even refer them to services in their local area.</p>
<p>On the downside though, it seems to take longer to gain the confidence of the people they were talking to on the sites. Where once conversations could be struck up in person, they now have all sorts of hurdles to overcome. Users of online services and social networks said they found it less easy to trust others on the sites and were concerned about being watched.</p>
<p>And although they saw the Terrence Higgins Trust as a reliable source of information about HIV and AIDS, there was a need to go the extra mile to prove the reliability of the information being provided. Online life is filled with hoaxes and scams. Getting users to trust that it really was THT online, offering support, was a major challenge to the outreach team.</p>
<p>There is still very much a need to inform people about HIV and AIDS. There were only 390 deaths from AIDS in the UK last year but HIV transmission rates continue to soar. As of January 2013, an estimated <a href="http://www.nat.org.uk/HIV-Facts/Statistics/Latest-UK-Statistics.aspx">98,400</a> people were living with HIV in the UK, including around 22,000 people who did not know they were HIV positive. In 2012 alone, there were <a href="http://www.nat.org.uk/HIV-Facts/Statistics/Latest-UK-Statistics.aspx">6,360 new HIV diagnoses</a>.</p>
<p>And while outreach workers make sense of how their traditional ways of working can be translated into digital outreach, there may well be a role for apps and websites to play too. The design and architecture of the commercial online platforms that are being used to bring men together with other men could themselves be improved to help outreach.</p>
<p>Unlike a bar, where people can shout across the room or have an intimate tête-à-tête, the design of an app like Grindr or a website like Gaydar means that discussions and chat happen largely out of sight. There is little opportunity for group discussion and outreach teams find it hard to break through and be seen. Bringing in functionality like this might be an important step in making sure the outreach workers can keep up with the new ways in which people are meeting each other in the digital age.</p><img src="https://counter.theconversation.com/content/23204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sharif Mowlabocus is a Senior Lecturer in Digital Media at the University of Sussex. For this research he received funding from the EPSRC's Cultures and Communities Network and the Terrence Higgins Trust.</span></em></p>Websites and apps such as Grindr and Scruff are booming as a new way for men to meet other men. But the people who seek to inform men about HIV and AIDS are finding they need to think on their feet to…Sharif Mowlabocus, Senior Lecturer of Media Studies and Digital Media, University of SussexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/216232013-12-19T14:53:13Z2013-12-19T14:53:13ZChoice on offer in brothels not consistent with sex trafficking<figure><img src="https://images.theconversation.com/files/38186/original/w28t6jv6-1387381195.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Claims that most off-street prostitutes have been "trafficked" are overegged.</span> <span class="attribution"><span class="source">Corn colonel</span></span></figcaption></figure><p>Cases in which women or children have been forced into prostitution under the violent control of a third party are often described as the tip of a very large iceberg. One of the principal statistical claims often presented in support of this view is that around 80% of female sex workers in Britain <a href="http://www.theguardian.com/commentisfree/2009/apr/02/women-sex-industry-trafficking-prostitution">are foreigners</a>, most of whom have been “trafficked”. </p>
<p>This claim derives from “<a href="http://i2.cmsfiles.com/eaves/2012/04/Sex-in-the-City-1751ff.pdf">Sex in the City</a>”, a 2004 study by the <a href="http://www.eavesforwomen.org.uk/about-eaves/our-projects/the-poppy-project">Poppy Project</a>, an NGO that provides accommodation and support services for “victims of trafficking” in the UK. This study comprises a telephone survey of indoor prostitution establishments and escort agencies in London, which enquired about “the location of each place, the numbers of women available, and their nationalities/ethnicities”. </p>
<p>The survey found that out of 8,000 sex workers in London, 80% were described as “foreign”. This finding, which has gone so far as to be submitted in <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhaff/23/23we19.htm">memos</a> to parliamentary committees, was set among anecdotal evidence from sexual health outreach projects and examples of individual cases of forced prostitution. The study concluded that: “Inevitably, many of these women will have been trafficked into the United Kingdom”. </p>
<p>At the time this report was published, Bridget Anderson and I were working on ESRC funded <a href="http://www.esrc.ac.uk/my-esrc/grants/R000239794/read">research</a> on the markets for migrant domestic and sex workers in the UK and Spain. When the Poppy Project’s study emerged, we identified various methodological problems with its research design. Given its overlap with our own research, we decided to replicate Poppy’s mapping exercise for our project; however, we also asked some additional questions to see what light we might shed on its claims about trafficking.</p>
<h2>What’s on offer and what it means</h2>
<p>Our added questions included asking about the services offered in each establishment (whether workers were willing to provide anal sex, oral sex without a condom and whether they were willing to kiss clients) and the prices charged for both vaginal and anal sex.</p>
<p>Using the methods the original authors described, we were only able to contact 148 establishments in London, whereas they reported contacting 730. Still, our findings were very similar as regards workers’ nationalities: only 20% were described as British. With regard to the services on offer, we found a high percentage of establishments reported their workers to be willing to kiss (73%). More disturbingly given the associated health risks, 60% reported that workers would be willing to provide oral sex without a condom. </p>
<p>However, less than a third of establishments reported that workers would provide anal sex; in only a quarter of cases was our researcher told that anal sex and oral sex without a condom and kissing would be available to him. There was also a significant difference between prices quoted for vaginal and anal sex. The mean price for a “full personal service” (vaginal sex) across all establishments contacted was £64, whereas the mean for anal sex was £97. </p>
<p>Any information on workers’ nationalities, services and prices gathered in this way comes with a strong methodological health warning. Still, these findings nonetheless pose a strong challenge to the idea that most of London’s indoor female sex workers are held in what is stereotypically represented as “sex slavery”. As evidenced in documented cases of forced prostitution, some of which are cited in the Poppy Report, women and girls who are locked into buildings and violently coerced into sex with clients are not normally given a choice as to which sexual services they provide. </p>
<p>Why, after all, would a “trafficker” who exercised total and direct control over a woman’s prostitution force her to kiss clients and provide oral sex without a condom, but allow her to refuse to provide anal sex when a client requested it? Why would such an individual instruct receptionists to tell prospective clients that anal sex is available, but not oral sex without a condom, or that workers are willing to provide oral sex without a condom but not to kiss? </p>
<p>The fact is that in 69% of cases our researcher, posing as a prospective client and asking “Does she do anal?” was told “No”, even though anal sex is a significantly more lucrative service. This suggests that more sex workers in indoor prostitution in London exercise rather more control over the details of their working practices than many commentators believe. </p>
<p>Meanwhile, receptionists in three-quarters of the establishments surveyed told our researcher that he would be refused at least one of the three services he named. This further undermines the assumption that overwhelming physical force or its threat is being used to subordinate most of London’s female prostitutes to the will of a “trafficker” or “pimp”. Nor does this constitute evidence that the remaining 25% must all be working under duress, since some independent sex workers are willing to provide all three services. All in all, our telephone survey (alongside other research) suggests that only a minority of sex workers are subject to the violent control of a third party. </p>
<p>As I have <a href="http://www.nottingham.ac.uk/icemic/documents/o-connelldavidson-icmic-wp-09-05.pdf">written before</a>, this should by no means be taken to imply that there is no such thing as coerced prostitution, or that those in the sex trade who are not subject to it are making a positive choice to sell sex. Indeed, that the groups apparently over-represented in prostitution (poor women, especially lone parents, and migrants) are particularly pressurised by our current welfare and immigration regimes suggests that prostitution is very likely a least-worst option for many people involved in it. </p>
<p>Instead, what this and similar insights do demand is that we ask whose interests are served by indiscriminate <a href="http://prostitutescollective.net/2013/12/05/police-raids-against-sex-workers-in-soho-central-london/">raids</a> on indoor prostitution establishments, currently represented as efforts to “rescue” women held in “sex slavery”. Like the Poppy Project’s research, such raids conflate migrants in the sex trade with “victims of trafficking” – at least, until they have been taken into custody, at which point they are most likely to find themselves re-categorised as “immigration offenders”. </p><img src="https://counter.theconversation.com/content/21623/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julia O'Connell Davidson received funding from the Economic and Social Research Council for the research upon which this article is based (Award No. R000239794), and currently holds a Leverhulme Major Research Fellowship for a project titled "Modern Slavery and the Margins of Freedom: Debtors, Detainees and Children"</span></em></p>Cases in which women or children have been forced into prostitution under the violent control of a third party are often described as the tip of a very large iceberg. One of the principal statistical claims…Julia O'Connell Davidson, Professor of Sociology, University of NottinghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/37812013-09-15T20:41:36Z2013-09-15T20:41:36ZA new approach to stopping the silent chlamydia epidemic<figure><img src="https://images.theconversation.com/files/31343/original/g9f26cxx-1379235989.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A new approach that
involves treating both partners is crucial to tackling escalating
rates of the often-asymptomatic disease of chlamydia</span> <span class="attribution"><span class="source">Pedro Figueiredo</span></span></figcaption></figure><p>A “Perspective” published in the <a href="https://www.mja.com.au/journal/2013/199/6/legislate-patient-delivered-partner-therapy-chlamydia?utm_source=MJA+news+alerts&utm_campaign=b18a2a56f3-Volume_199_6_16_September_20139_13_2013&utm_medium=email&utm_term=0_8c7e70a099-b18a2a56f3-31403861">Medical Journal of Australia</a> today calls for patient-delivered partner therapy for chlamydia to be made legal across Australia. This approach could be just the right way to tackle the growing problem posed by this sexually transmitted infection.</p>
<p>Patient-delivered partner therapy entails the person being treated for chlamydia receiving antibiotics for her partner (for reasons you will learn below, it’s usually a woman who is being treated for the infection). Chlamydia is a bacterial infection that can damage a woman’s reproductive organs; it can result in a discharge through the urethra for men. </p>
<p>It’s not a “one-off” infection, so people can be reinfected a number of times. Chlamydia is transmitted through sexual contact – vaginal, oral or anal – and can also be passed to a baby by an infected mother during vaginal birth.</p>
<p>Reinfection from partners is common for the illness but providing patients with medication for their partner has uncertain legal status in most Australian states and territories.</p>
<h2>Upward trajectory of harms</h2>
<p>Chlamydia has become the most common sexually transmissible infection in Australia; nearly 80,000 infections were reported in 2011, compared to only around 17,000 in 2001. </p>
<p>In women aged between 15 and 19 years, the rate increased fivefold over this period, while for the same male age group, it increased fourfold.</p>
<p>Chlamydia is often asymptomatic, which means people with the disease may not know they have it, even though it’s easily detectable through a urine test and treatable with antibiotics.</p>
<p>Because it is often asymptomatic, chlamydia causes little immediate pain and discomfort. But it can cause pelvic inflammatory disease in women, which can be painful and damage the uterus and fallopian tubes through scarring of tissue. And this can lead to tubal infertility and ectopic pregnancy. </p>
<p><a href="http://www.ncbi.nlm.nih.gov/pubmed/14681509">Research evidence suggests</a> that around two-thirds of cases of tubal infertility and one-third of ectopic pregnancy cases could be linked to past chlamydial infection. </p>
<p>While pelvic inflammatory disease can be treated with antibiotics, it’s better to prevent it by screening for, and treating, chlamydia. </p>
<p>With more women waiting until they are older to have their first child, some are finding that undiagnosed chlamydia has had a negative impact on their fertility and are faced with undergoing difficult and expensive IVF treatment.</p>
<h2>Why no treatment?</h2>
<p>There are three big problems when it comes to detecting and treating chlamydia. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/31342/original/4pfd5j87-1379235767.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chlamydia infection caused by the bacteria Chlamydia trachomatis.</span>
<span class="attribution"><span class="source">AJ Cann</span></span>
</figcaption>
</figure>
<p>The first is the “silent” nature of the infection, which means it’s not easily detected because there are no symptoms. This also means that there’s a lack of awareness among young people (in particular) about chlamydia and its potential impact. </p>
<p>The second issue is the limited nature of screening options. Although screening is available at doctors’ clinics, women are most often screened when they go for a script for the pill or for a Pap test. </p>
<p>Very few men, particularly young men, ever go to a doctor or a sexual health clinic for a test, so their chlamydial infection often goes undetected. This means they can infect any woman or man they have unprotected sex with. </p>
<p>Research has shown that screening for chlamydia <a href="http://www.publish.csiro.au/paper/SHv4n4Ab8.htm">where young people congregate</a>, such as higher education institutions, can be effective. Other venues, such as <a href="http://www.biomedcentral.com/1471-2334/9/73">car rallies and sporting clubs</a> have also been shown to be feasible when targeting young men for chlamydia screening. </p>
<p>Other research suggests community pharmacies may be effective for screening high-risk groups and those who do not regularly see a doctor.</p>
<h2>A possible solution</h2>
<p>The third difficulty is providing treatment for the sexual partners of people getting treatment. Treating chlamydia in one sexual partner and not the other will lead to reinfection or the infection of future sexual partners. </p>
<p>And here’s where the Perspectives piece in the MJA is interesting. In 2006, the US Centers for Disease Control and Prevention <a href="http://www.cdc.gov/std/treatment/EPTFinalReport2006.pdf">recommended partner-delivered therapy</a> and it’s now legal in most US states. </p>
<p>But it’s either illegal or has an ambiguous legal status in Australian states and territories. Even though a <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1801006/">2007 meta-analysis</a> of five studies of the approach showed it was effective.</p>
<p>There are guidelines for the approach endorsed by the <a href="http://www.racp.edu.au/index.cfm?objectid=2559E099-C37A-98A1-117CDED895CFF46C">Australasian Chapter of Sexual Health Medicine</a> (a chapter of the Royal Australasian College of Physicians), and the <a href="http://www.asid.net.au/">Australasian Society for Infectious Diseases.</a> </p>
<p>Partner-delivered therapy has the potential to treat more people infected with chlamydia and help curtail the infection rate in the population.</p>
<p>We need a multi-faceted approach to deal with the chlamydia epidemic. Educating young people and providing screening in accessible and places that are convenient for them is a start. </p>
<p>But we also need to keep in mind that, for every notified infection, there’s probably at least one infected sexual partner.</p>
<p>The longer we fail to provide treatment for both patients and partners, the greater the burden of infection we will have in the community. And the more we risk chlamydia impacting the fertility of young women, both in terms of private pain and the cost of infertility treatment.</p><img src="https://counter.theconversation.com/content/3781/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rhian Parker has conducted funded research on chlamydia. The views expressed here are not necessarily those of the organisations that have funded these research projects</span></em></p>A “Perspective” published in the Medical Journal of Australia today calls for patient-delivered partner therapy for chlamydia to be made legal across Australia. This approach could be just the right way…Rhian Parker, Associate Professor and Senior Research Fellow, Centre for Research and Action in Public Health, University of CanberraLicensed as Creative Commons – attribution, no derivatives.