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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  • Helen Tolbert

    Dr. Ariba God will continue to bless you more abundantly, for the good works you are doing in peoples life, I will keep on writng and posting testimonies about you on the Internet, I’m Helen Tolbert, I was a HIV patient, I saw a blog on how Dr. Ariba cured someone, I contacted him and also got my healing, kindly email him now on [email protected] Or [email protected] email me on [email protected]…….

  • Helen Tolbert

    Dr. Ariba God will continue to bless you more abundantly, for the good works you are doing in peoples life, I will keep on writng and posting testimonies about you on the Internet, I’m Helen Tolbert, I was a HIV patient, I saw a blog on how Dr. Ariba cured someone, I contacted him and also got my healing, kindly email him now on [email protected] Or [email protected] email me on [email protected]

  • 4th Turning

    Agree. Mostly intended as a sidebar since it is another problem of growing concern.
    Can’t imagine what kind of feedback you receive other than what appears here, but
    I feel certain your posts are passed along to how many others by parents, friends,
    mentors. teachers, etc. I know or know of all the doctors in my rural area. The most
    caring healthcare professionals here are P.As and nurse practitioners… The docs
    are too preoccupied with typing shit into their laptops to listen. None are into any-
    thing approaching wholistic or trying to get their heads around gay-related health
    concerns/issues. The medical establishment, here anyway, feels no obligation to
    promote the “basic education” you reference. Waiting room walls are totally
    empty of simple educ. posters Magazines are Golf and B H and Gs. from
    5 yrs ago. So many wasted opportunities to involve both the healthy and
    sick in better selfcare maintenance and outcomes.
    Commenters who live in metro areas w/gay yellow pages full of gay friendly
    practices should count themselves very lucky.
    I don’t know whether the possibility is discussed in your circles but I have a disconcerting feeling there is some kind of subconscious suicidal affect going on when the whole raft of negative “risky” behaviors are taken together.

  • Butch1

    Perhaps I’m trying to reach them in a positive way rather than having them not listen at all by putting up their defense mechanisms with a long lecture as to why they are killing themselves in a negative way.

    I’m still looking at the people and not the disease.

  • Butch1

    Perhaps I’m trying to reach them in a positive way rather than having them not listen at all by putting up their defense mechanisms with a long lecture as to why they are killing themselves in a negative way.

    I’m still looking at the people and not the disease.

  • docsterx

    From what I’ve seen, getting reliable statistics is often a problem. People are ashamed that they ight have an STI and therefore don’t seek treatment. Then the chancre goes away and they feel relieved and safe, but are still highly infectious. Shame

    Some sex education classes are extremely limited in what they teach. This can be because of local laws, religious beliefs or other reasons. Lack of education

    Some groups don’t have access to condoms or can’t afford them. Some don’t have easy access to medical professionals who can diagnose and treat them. No access to treatment

    These are some of several reasons why people don’t seek treatment. Generally, in countries where there are good sex education programs in schools, sex can be discussed freely at home, in schools, in counseling centers, etc. rates are lower. The same with access to care, those countries who promote easy access to diagnosis and treatment often have lower STI rates.

    Sen is a normal act. People don’t feel shame if they get a sore throat. But, if the sore throat is caused by gonorrhea, they probably will. Because it’s attached to sex and sex is bad and taboo to talk about.

    Estimates of STI rates seem to show that in smaller countries, with more homogeneous populations, better sex education and better education about STIs, easier access to condoms, diagnosis and treatment, the syphilis incidence is lower. ON the other hand, countries with high populations of sex workers, countries where medical care is limited, education is limited, the STI rates increase. China, some other areas of Asia and several areas of Africa have high instances of syphilis. Elsewhere in the world, there are some hotspots of infection. But primarily, other than the above named areas, incidence of syphilis is low.

    Japan is thought to have a low rate of STIs as are countries like Montevideo.

  • Indigo

    To me, a spike in the STD rate is the tip of a possible iceberg. This sounds uncomfortably like the late 70s when STD rates among gay men were soaring upwards, warnings were out everywhere to use safe sex techniques, condoms at the least, but the party crowd ignored the warnings, possibly too busy partying to notice the red flags flying in many gay community spots, advisory bulletins about safe sex were posted in the bath houses and even in ‘The Advocate’ then printed on cheap newsprint with ink that smeared. The warnings were clear. By the very end of the 70s, pneumonia swept away many, that in turn came to be thought of as gay-related so whatever it was, it was renamed GRID (gay-related immune-deficiency) and finally medical research identified AIDS with an actual name but by then an entire party crowd was infected and now . . . they’re all gone.

  • Mike_in_the_Tundra

    I was going to argue with you about scaring people. I thought that those of us who lived in the eighties were scared enough to last a lifetime, but I think it may be the grief that has stayed with us. Thinking of that time gives me a physical pain.

  • docsterx

    I don’t think that “goodness” is in any way involved in this.

  • docsterx

    With the attitude that some of them have, I don’t think that talking about antibiotic resistance would make a dent. Scaring people to get them to change behaviors works, but only short-term. After about a month or so, the old “That won’t happen to me” feeling returns and the old behaviors re-emerge. I think we need to present the risks of unprotected sex, what the safer options are, doing a lot of basic education individually and in small groups, along with a little scaring about the possible consequences: what it can do to you, other sexual contacts, any children that you might have, etc.

  • docsterx

    Thanks for the information and your perspective, Ken. Good to hear first-hand information from someone out in the trenches.

    The cockiness and fearlessness is really alarming. Hot telling partners that a patient is positive can not only be virtually a homicidal act in some cases, but illegal in some states. And the “I’ve got HIV, I’ll just take a pill” attitude is equally insane. Even if the HIV is well-controlled there are som many other factors to look at and problems to deal with that this sttitude is breathtakingly foolish.

    Ken, do you have a link for the study that you worked on? I’d like to read it. Thanks again!

  • Butch1

    Is it “cool” to be play dumb and not want to learn anything about sex education or rather will your peers think you are uncool if you want to know all the facts about sex education?

    For goodness sake it’s your own life you’re messing with and all it takes is just one time to literally screw it up.

  • Julien Pierre

    More times than I can count !
    2 more just since the above message I posted yesterday.
    People just don’t know what the word means.
    If you say just poz, they are clueless. “HIV poz”, they usually understand.

  • 4th Turning

    Have actually overheard some straight young people laughing off risky overnight heat saying a trip
    to the health dept. will fix everything.
    Doc, you need to explain how each and every injection of penicillin increases probabilities of antibiotic
    resistant stds…
    I’m also of the opinion that whatever hiv-aids vaccine may be on the near or far horizon will only
    translate into a “get out of latex free” card and we will be back to square one…

  • http://AMERICAblog.com/ John Aravosis

    You’ve had to explain the meaning of “poz”?

  • guest

    Are there other countries doing a better job on this? Did anybody check around? How ’bout anonymous testing programs?

  • Julien Pierre

    It only takes one mistake to be infected with HIV.

    1. There is a known very high rate of unsafe sex on grindr and other hookup apps/sites
    2. People who are recently infected are the most likely to transmit HIV
    3. People who are recently infected also still test negative on antibody screening tests due to the window period of those tests, giving others a false sense a safety
    4. It is estimated that as many as 50% of all HIV transmission happen as a result of recent infections

    When you consider those 4, it’s unfortunately no surprise that the rate of HIV transmission is not going down. Unfortunately, most people are not aware of points 2, 3 and 4 . I believe they would make better decisions and have less unsafe sex if they understood this, or use PEP or PrEP. I think sex education has failed in a major when when it comes to HIV. Simply staying away from men who are known to be HIV positive – ie. serosorting – is not an effective safe sex strategy.

    I have grown really, really tired of being the one on which it falls
    to give sex ed lessons on grindr. So I put together a page that lists a
    few things every gay man should know about HIV, but unfortunately these facts are mostly known to HIV positive men.

    See http://tinyurl.com/hiv404

  • Julien Pierre

    I agree that the younger generations are less fearful of HIV, overall. I think this is at least partly justified. While the probability of catching it hasn’t gone down, the probability of progressing to AIDS are much less due to the existence and increased availability of current treatments. HIV just isn’t a death sentence like it used to be. Of course, that doesn’t mean one should take unnecessary risks.

    I am HIV positive, and while I am not ashamed of it, I certainly would not consider it a badge of honor. I have never met anyone that held that opinion, either.

    I do have my status listed in my grindr profile. Many others never even read it and just look at the pretty picture.

    A shocking number do not even know the meaning of the word “poz” – a lot of good it does for one to be part of the “poz tribe” on grindr. Of which there is probably a single digit number in the entire SF bay area at any one time, if you can fathom that. The HIV stigma is still alive and well, unfortunately. I believe most HIV+ men disclose their status, but they don’t advertise it, making it nearly impossible to find each other.

    I have probably had to explain the meaning of poz dozens of times. Many will understandably be fearful. Some will just rudely end the conversation and block afterwards.

    I have grown really, really tired of being the one on which it falls to give sex ed lessons on grindr. So I put together a page that lists a few things every gay man should know about HIV, but unfortunately most are known only to HIV positive men.

    See http://tinyurl.com/hiv404

  • http://AMERICAblog.com/ John Aravosis

    Dear Lord. I’d not heard of the badge of honor thing either. How seriously f’d up. Though I’d talked to friends about this a while back, about the fact that younger gays today didn’t get to watch their friends die, and thus they have an entirely different formation, formative years, as concerns growing up young and gay. So while I get that they aren’t as afraid of HIV, which is still seriously f’d, up the idea of it being a badge of honor. Jesus. Also, we’ve had lively discussions before about the responsibility of HIV+, hepatitis +, syphilis + people fessing up before sex.

    I’m blown away when I see these guys in the neighborhood on Grindr or Manhunt, who are all of 23, young, apparently of a certain economic class that’s higher than blue-collar, appear to not have exactly grown up on the DL, yet end up HIV positive, at that age, in this age.

  • Thom Allen

    Thanks, Ken. I didn’t mention the relative fearlessness of the younger MSM, since, from what I read that was more closely linked with HIV and not syphilis.

    I’ve not heard about the “badge of belonging” idea before. Or the idea that it’s assumed to be OK for the HIV positive guys to keep their diagnosis a secret. Both of those are really frightening. Even if they didn’t experience the thousands of deaths from AIDS in the 80s and 90s, they should still realize just how serious HIV is.

    It doesn’t bode well for controlling any of the rates of STDs in this group if they have such a cavalier attitude.

    Thanks for the information and your perspective. Do you have a link to this data? I’d like to see it. If you don’t want to post it here, you can send it to [email protected] and he can forward it to me. Thanks!

  • Ken

    To offer one perspective on this, I helped conduct a study of HIV+ MSM, the STD and hepatitis prevention messages they were receiving from HIV clinics, and their attitudes on safe sex, where I did in-depth interviews with hundreds of HIV+ MSM in cities around the US. One thing we found was that young MSM do not have the same fear of HIV as the older generation, because with the new drugs it is not always an immediate death sentence, thus they are not as careful about safe sex. A common opinion among many of the HIV+ MSM with whom I spoke was that for some of the younger generation being HIV+ is considered a positive thing, a sort of badge of belonging, a way to be part of the scene, and this lack of fear and actual positive attitude toward HIV infection (and lack of fear of other STDs such as syphilis) caused them to reject safe sex. The fear, of course, is that these increases in STDs among MSM are not only bad because syphilis and gonorrhea are bad, but because it may also cause an increase in HIV transmission. A common opinion among MSM was that in situations where MSM are getting together for purposes of sex many believed that it’s not up to the HIV+ person to inform others that he is positive, it should be assumed, and that it’s up to the HIV- men to find that out and initiate condom use. This lack of communication, and lack of fear of HIV, does not bode well for controlling the syphilis rates.

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