Syphilis cases rising sharply among young gay men

Syphilis rates are continuing to rise in men who have sex with men (MSMs.)

The Centers for Disease Control defines MSMs as gay and bisexual men and other men who have sex with men. The latter includes men who have episodic sex with men but do not consider themselves either gay or bisexual.

Sometimes MSMs can be men from, for example, the African-American community, who are having sex on the “down low.” They rarely consider themselves as gay or bisexual, and often are unaware that they have a risk of developing HIV or other sexually transmitted infections (STIs) that are more common in MSMs.

Hidden man, via Shutterstock

Hidden man, via Shutterstock

Or these may be men who rarely have gay sex, but when they do, ascribe the reason to being drunk or high. So they don’t consider themselves to be a member of the bisexual population either, since they normally have sex with women.

Or an MSM can be a teenager who has just tried gay sex once at this point in his life, and isn’t quite sure what he is.

One of the reasons that this group is important is that they have a higher risk of developing syphilis and HIV.

Syphilis is on the rise among young MSMs

Cases of syphilis have been reported to health departments for decades. This was done, in part, to try to eradicate syphilis (and later, other sexually transmitted diseases.) At that time, there were doctors who had caseloads heavy with syphilis patients, so high that they were referred to as “Syphilologists.”

In the intervening years, syphilis rates have declined, increased and declined. In 2000, reported syphilis cases were at their nadir. But since 2000, the incidence of syphilis has increased. In some populations, the increase has been dramatic. In other populations, it’s been a relatively minor increase. And in some populations, it’s declined.

From the CDC:

In 2005, CDC began collecting information on the sex partners of patients with P&S [primary and secondary syphilis] syphilis. In 2012, this information was available for 82% of male cases. During 2007–2012, 33 areas reported sex of partner data for at least 70% of cases each year during this time period (Figure 30). During 2007–2008 in these areas, increases in cases occurred among women, men having sex with women only (MSW), and MSM. During 2008–2012 in these areas, cases among women and MSW declined 24% (from 1,364 to 1,034 cases) and 15% (from 1,884 to 1,600 cases), respectively, while cases among MSM increased 46% (from 5,872 to 8,553 cases). During 2011–2012 in these areas, cases increased very slightly among MSW (4%) and women (1%), while cases among MSM increased 15% (from 7,422 cases in 2011 to 8,553 cases in 2012)—a larger increase than in previous years. (In these areas, cases among MSM increased 6% during 2008–2009 (from 5,872 to 6,243), 10% during 2009–2010 (from 6,243 to 6,870 cases), and 8% during 2010–2011 (from 6,870 to 7,422 cases).) In 2012, among MSW with P&S syphilis, 39.2% had primary syphilis, and 60.8% had secondary syphilis. Among women with P&S syphilis, 18.6% had primary syphilis, and 81.4% had secondary syphilis. Among MSM, 27.2% had primary syphilis, and 72.8% had secondary syphilis (Figure 39).Among women with P&S syphilis, 18.1% were white, 65.2% were black, 13.2% were Hispanic, and 2.5% were of other races/ethnicities. Among MSW, 20.4% were white, 55.9% were black, 19.2% were Hispanic, and 2.8% were of other races/ethnicities. Among MSM, 37.9% were white, 34.4% were black, 21.1% were Hispanic, and 4.5% were of other races/ethnicities (Figure 40).

[ . . . ]

In recent years, young MSM have accounted for an increasing proportion of syphilis cases in the United States.9, 10 According to information reported from 49 states and the District of Columbia, 75% of P&S syphilis cases are among MSM. Although the majority of U.S. syphilis cases have occurred among MSM, transmission among MSW and women continues to occur in certain jurisdictions. [Emphasis mine]

Why are young MSMs at highest risk? There are a number of possible reasons. Some are similar to reasons that this same population is at higher risk for HIV infection.

One is lack of knowledge. Men in these age groups may not have gotten much information on STIs through sex education classes, information available in the community, from health departments, etc. They may be unaware of how they are at risk and how to protect themselves.

They may deny that they have any symptoms of an infection or wait for it to resolve on its own. And when the chancre (the primary sore of syphilis, present at the site of entry of the organism) disappears (as it will even without treatment) they may feel relieved and secure. Not realizing that the disease is progressing to secondary syphilis. They may have no one to turn to for good information. Possibly fear of being stigmatized for having gay sex (or, in some families, any sex out of wedlock.) MSMs also have higher numbers of lifetime sex partners and may have higher rates of unprotected sex. Some men at this age are experimenting with drugs and alcohol and being under the influence of either can increase risk-taking behaviors.

The CDC also adds:

. . . other interpersonal and societal-level factors have also been associated with higher rates of sexually transmitted infections, including HIV among MSM.7 MSM who have lower economic status are particularly vulnerable to poorer health outcomes, especially if they belong to racial and ethnic minority populations.8, 9 For example, studies show that for black MSM, factors such as emotional and social support can drive sexual risk-taking and, in addition, broader societal factors such as power, privilege, and position in society also play a significant role.10 Similarly, for Hispanic men, the relationship between individual experiences of oppression (e.g., social discrimination and financial hardship) and risk for sexually transmitted infections in the United States has been documented.

For all of these reasons, and others, this heterogeneous group, is at higher risk for syphilis.

If they do contract syphilis, this also puts them at higher risk to become infected with HIV. Men with penile lesions from STIs (such as syphilis, chancroid, herpes) have an increased risk of contracting HIV. So an uptick in syphilis cases (or herpes or chancroid cases) can signal that an increase in HIV diagnoses may well follow.

What can be done about this increase?

Some things come to mind.

One is education.

Get information to this target population, not just on syphilis but other STIs as well. One method may be through social media. The CDC and a number of other sites have Facebook profiles and tweet on Twitter. Another option is to make sure that safe-sex information, and information on STIs is taught in schools. Adequately taught with correct information and not just glossed over. Mention that abstinence works. That limiting the number of sex partners can reduce the risk of contracting an STI. Have information available (such as phone numbers for 24 hour STI hotlines (see below)) at places where teens and young adults congregate (clubs, bars, gyms and other sites.) We can act as mentors, talking with other men and helping to inform them through sharing information and support.

Provide easy access to condoms and health care for STIs.

Some county health departments have satellite clinics in several areas of their counties to provide just such services along with testing for STIs. Provide information and access to PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis.) While these two won’t do anything to stop syphilis, they can prevent HIV cases in people who currently have syphilis.

We need to encourage them to be open and clear when talking to health professionals about sex, sexual history, partners, type of sexual contact, etc. (A recent survey showed that about >40% or teens polled didn’t think that oral sex was a sexual contact at all. They thought that only penis-vagina contact with penetration was sex. And, therefore, they weren’t at risk to get an STI because oral sex wasn’t “sex” as they defined it.)

Be honest with sex partners.

Don’t minimize risks of previous sexual contacts to a new partner.

Spread the word that having sex while under the influence of drugs and/or alcohol can increase the risk of getting syphilis, HIV and other STIs.

None of these alone, or in combination, can be guaranteed to eliminate syphilis, HIV or other STIs. Using them consistently can certainly cut down on the number of cases of syphilis and other sexually transmitted infections. That would be a great start for all MSMs whether they be gay, bisexual or don’t identify as either but still have sex with men.

More info:

CDC 24 hour STI hotline and website (English and Spanish):
Website: CDC National STD Hotline (in Spanish)
Toll-free: 1-800-232-4636 (24 hrs. in English and Spanish)
TTY: 1-888-232-6348 (in English and Spanish)


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Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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