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Translated by Zoe Yarymowich
I have long believed that I was cursed in terms of sexual partners. It is not because I have lousy lovers - quite the contrary, but because I often have to argue endlessly to get them to put on a condom. I know their excuses by heart: “I don’t want to put on a condom because it’s too tight”, “It makes it harder for me to feel something”, “It doesn’t matter, you’re already on the pill”, “Don’t worry, I’m clean”, etc. When I insist, they inevitably say, “Oh come on, relax, you’re paranoid.” Rare are those who agree to put one on. I swear I am not exaggerating even a little bit.
Sexually transmitted and blood-borne infections or STBBIs are becoming a real pest (Grandad, if you are reading this, they were called venereal diseases in your day). Of course, STBBIs are not as bad as the Black Death of the Middle Ages, and I may be seeing the problem as worse than it is, given that I am writing my master’s thesis on one aspect of the subject. The fact remains that the reported rate of STBBIs in Quebec and Canada has increased dramatically in recent years and, in my opinion, this is an insidious problem to which not enough attention is paid.
One, Two, Three, Four, Chlamydia or Something More?
Paranoid, you say? I do not think so. The numbers speak for themselves. Since the late 1990s, cases of chlamydia, gonorrhea, and syphilis have increased at alarming rates in Canada (PHAC, 2011; PHAC, 2013). Nationally, there was a 72% increase in cases of chlamydia, 53% in cases of gonorrhea, and 457% in cases of syphilis between 2001 and 2010 (PHAC, 2013).
In Quebec, chlamydia takes home the gold in terms of incidence (INSPQ, 2015; PHAC, 2015). In 2014, Quebec alone reported 23,198 cases of chlamydia compared to 17,362 cases reported just four years prior. This represents an infection rate of 282.1 per 100,000 people (INSPQ, 2015). To compare, the gross incident rate for salmonellosis in 2014 in Quebec was 18.01, the gastroenteritis epidemic was 4.87, and Lyme disease was 1.47 per 100,000 people (INSPQ, 2015).
Still unconvinced? In 2014, Quebec saw 29,000 cases of STBBIs, which represents 75% of the illnesses reported in Quebec’s notifiable disease database (MADO) (INSPQ, 2015). STBBIs that were thought to be in decline (such as Lymphogranuloma venereum [LGV], for example) are regaining attention and contributing to the rise in the reported rate of STBBIs (INSPQ, 2015).
What is worrying is that this trend is continuing to grow
(INSPQ, 2015; PHAC, 2013).
Although there was a notable increase in the rate of STBBIs among the elderly (party in the CHSLD, right Grandma?), the most affected age group is that of teenagers and young adults (15-29 years old; INSPQ, 2015; OPH, 2011; PHAC, 2013). Indeed, in 2010, the highest rate of gonococcal infections (gonorrhea) was among 15-19 year-olds, while the highest rate of Chlamydia trachomatis (chlamydia) was among 20-24 year-olds (PHAC, 2013). Still, think I am paranoid?
Four, Five, Six, and Maybe Syphilis
Of course, this considerable rise in STBBIs, which has been recorded over the last twenty years, cannot solely be because the number of infections and those infected is increasing. Indeed, many different factors have contributed to this phenomenon.
Firstly, screening tests have evolved and are far more accurate than before. In addition to being able to detect infection earlier (thank you, NAAT; nucleic-acid amplification tests; INSPQ, n.d; PHAC, 2011; PHAC, 2013), they can now also detect extragenital infections (e.g., rectal infections with Chlamydia trachomatis; INSPQ, 2015). The number of these tests has also risen by 31% between 2009 and 2014 (INSPQ, 2015). Thus, some cases of STBBIs, which were imperceptible before, can now be detected (OPH, 2011). Similarly, it is now easier to get an exact history of a patient’s sexual partner(s) through the use of tracing techniques, such as the social networking approach, which makes it possible to trace more infected people in a much more effective and precise way (Ogilvie et al., 2005; PHAC, 2011).
Secondly, the fact that individuals are living longer sexually active lives (starting younger and ending later) is not unrelated to the phenomena. Indeed, young people are becoming sexually active at an increasingly younger age and have a higher frequency of relations (INSPQ, n.d.). The general population is also staying sexually active for longer (thank you, Viagra and co.) (Steben and Laberge, 2006). Likewise, the use of online dating websites and apps such as Tinder and Bumble allows, for easier access to multiple sexual partners and further exposes the population to various STBBIs (Bhattacharya, 2015; INSPQ, n.d.).
Another factor that may explain the colossal increase in the rate STBBIs is the phenomenon of safe-sex fatigue or condom fatigue. This phenomenon is defined by the decline in the popularity of condom usage (Rowniak, 2009). This can be explained, in part, by the fact that users no longer see the point of using one (Rowniak, 2009). In fact, for the past ten years or so, a certain weariness or complacency has arisen regarding the use of condoms.
This condom laziness translates into indifference towards protection during sexual intercourse and recklessness concerning STBBIs (Rowniak, 2009).
During the 1980s and 1990s, fear of the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) was much more present than it is now and it incited people to protect themselves during sexual relations (Aral et al., 2006; Steben & Laberge, 2006). Nowadays, a false belief seems to be gaining ground; we can now cure HIV/AIDS. This erroneous belief, which I often hear during the sexual education workshops that I co-host, is unfounded. The current technology makes it possible to treat HIV thanks to a combination of antiretrovirals that control the replication of the virus, but cannot cure or eradicate it totally (the Berlin patient being the exception) (PVSQ, 2016).
Another major factor that explains the rise in the rate of STBBIs is misinformation and a lack of education. Despite all of the efforts made in public health to educate people on their sexual health, there is still an enormous amount of work to be done. Each day, I hear myths and misconceptions about sexual or reproductive health during the workshops I give in high schools, but also during radio interviews, on social media and in my social spheres, etc. There is a cruel lack of knowledge about sexuality. Our Western society remains ill-advised on matters of sexual health. Just in terms of STBBIs, the lack of knowledge is glaring. For those who aspire to work or are already working in the field of sexual health, I am almost certain that you too will hear the following statements and will have to provide details to correct them:
“If I have no symptoms, I can be certain that I do not have an STBBI.”
This is false. Many infected people do not show any symptoms. For example, in the case of a Chlamydia trachomatis infection, only about 10% of men and 5 to 30% of women display symptoms (Farley et al., 2003; Korenromp et al., 2002), this is why it is important to encourage people to regularly undergo screening tests, especially if they have multiple partners and even more so if they do not use any method of protection against STBBIs.
“I always use a condom with my partners.”
I always ask them if they also use a condom during oral sex. Because, yes, STBBIs can be transmitted orally (PVSQ, 2016), hence the usefulness of dental dams for cunnilingus and anilingus (rimming) or a male (external) condom during blowjobs. While it is certainly less spontaneous, healthy sexuality is very sexy!
“No, I am not protecting myself, but it doesn’t matter! At worst, a quick round of antibiotics and boom, back in business!”
False. The modern echoes of the effects of the discovery of penicillin can be seen here: an indifference and a certain complacency on the part of the public concerning STBBIs (CPHL, n.d.). When faced with this kind of statement, one must set the record straight by explaining that although some STBBIs can be cured with antibiotic treatment, the situation is becoming more complex because of the phenomenon of antimicrobial resistance.
Indeed, some STBBIs that could previously be cured are no longer curable: certain micro-organisms have adapted and antibiotics no longer have any effect on the infection (Government of Canada, 2014). For example, some strains of gonococcus have been found to be multidrug-resistant (WHO, 2016). It is thus impossible to cure them with current treatments (PHAC-2, 2013). Currently, there are 32 resistant gonorrhea strains which account for 60% of gonorrhea cases worldwide (PHAC-2, 2013). Finally, even if some bacterial STBBIs can be cured with antibiotics, others can not be at all: they stay with us for life. For example, this is the case for HIV or herpes. People must be made aware of this false sense of security which can reassure them when they engage in risky behaviours.
Seven, Eight, Nine, Ten...Oh No Not Again!
There is also the popular belief that if no symptoms are present it must not be that bad, so why go to the effort to treat it? It is important to explain that STBBIs can have serious consequences. In the short term, in addition to having to undergo all of the usual symptoms that can accompany an STBBI, having one can triple the chances of contracting HIV (especially in the case of herpes, syphilis, or trichomonas; WHO, 2016).
In the long term, STBBIs can cause infertility, ectopic pregnancies (Mayaud and McCormick, 2001; PHAC, 2013; WHO, 2016), damage to internal organs such as the liver, cancers of the sexual organs (such as cervical cancer; PHAC, 2013), genital lesions, weakening of the immune system (Santé Publique Outaouais, n.d.), chronic pain (Santé Montréal, 2015), epididymitis (INSPQ, n.d.), etc. Apart from the physical consequences, there are also non-negligible social, psychological, and interpersonal consequences to being infected with an STBBI. Imagine the economic cost of intaking all of these infected patients. Given that the purse strings have been quite tight lately on the health policy side, it would make sense to invest in prevention, because at the end of the day, it is pretty much the only option that would help decrease the high rates of STBBIs observed over the past 25 years (Chesson et al., 2008).
Nine, Ten, Eleven, Twelve, You Must Protect Yourselves!
Overall, it is better to prevent than cure, even if it is cliché. The rate of STBBIs is on the rise, both here and elsewhere in the world (WHO-2, 2016) and it is imperative to act now before it is too late (read: before the apocalyptic era where antibiotics do nothing for us).
Promote safe-sex practices instead of risky ones by sharing information and educating the population.
For those in a full crusade against the condom, other barrier methods that protect against STBBIs exist: the underrated female (internal) condom (but be patient because they are hard to find), and maybe soon the invisible condom. Even better, there may soon be vaccines that protect against the most common STBBIs. Utopian? Not so much, given that a research team at McMaster University found a new chlamydia antigen (BD584), which could potentially be a candidate for a vaccine (McMaster University, 2017). In the meantime, as one of my colleagues would say:
“Protect yourself, or stay home!”
Aral, S.O., Over, M., Manhart, L., & Holmes K.K. (2006). Sexually Transmitted Infections. Disease Control Priorities in Developing Countries (Chapitre 17). https://www.ncbi.nlm.nih.gov/books/NBK11734/
Bhattacharya, S. (2015). Swipe and burn. New Scientist, 225(3002), 30-33. https://doi.org/10.1016/S0262-4079(15)60032-X
Canada’s Public Health Leader (CPHL). (n.d.) Fighting the Good Fight! From VD to HIV/AIDS. http://www.cpha.ca/en/programs/history/achievements/02-id/02-vd_to_hiv.aspx
Chesson, H.W., Collins, D., & Koski, K. (2008). Formulas for estimating the costs averted by sexually transmitted infection (STI) prevention programs in the United States. Cost Effectiveness and Resource Allocation, 6, 10. https://doi.org/10.1186/1478-7547-6-10
Farley, T.A., Cohen, D.A., & Elkins, W. (2003). Asymptomatic sexually transmitted diseases: the case for screening. Preventive medicine, 36(4), 502-509. https://doi.org/10.1016/S0091-7435(02)00058-0
Gouvernement du Canada. (2014). Résistance aux antibiotiques (antimicrobiens). https://www.canada.ca/fr/sante-publique/services/resistance-aux-antibiotiques-antimicrobiens/propos-resistance-aux-antibiotiques.html
Gouvernement du Québec. (2015). Vigie et surveillance des maladies à déclaration obligatoire d’origine infectieuse : maladie d’origine infectieuse. http://publications.msss.gouv.qc.ca/msss/fichiers/2015/15-268-03W.pdf
Groupe de travail. Guide d’intervention ITS-MADO. (2014). Guide d’intervention : Infections transmissibles sexuellement à déclaration obligatoire. http://publications.msss.gouv.qc.ca/msss/fichiers/2014/14-271-01W.pdf
Institut National de Santé Publique du Québec (INSPQ). (2015). Portrait des infections transmissibles sexuellement et par le sang (ITSS) au Québec. https://www.inspq.qc.ca/sites/default/files/publications/2067_portrait_infections_sexuellement_sang.pdf
Institut National de Santé Publique du Québec (INSPQ). (n.d.). Infections transmissibles sexuellement et par le sang (ITSS). https://www.inspq.qc.ca/sites/default/files/responsabilite-populationnelle/f007_itsss.pdf
Korenromp, E.L., Sudaryo, M.K., de Vlas, S.J., Gray, R.H., Sewankambo, N.K., Serwadda, D., Wawer, M.J., & Habbema, J.D. (2002). What proportion of episodes of gonorrhoea and chlamydia becomes symptomatic? International journal of STD & AIDS, 13(2), 91-101. https://doi.org/10.1258/0956462021924712
McMaster University. (2017). Researchers produce first widely protective vaccine against chlamydia. https://fhs.mcmaster.ca/main/vaccine_against_chlamydia.html
Mayaud, P., & McCormick, D. (2001). Interventions against sexually transmitted infections (STI) to prevent HIV infection. British Medical Bulletin, 58(1), 129-153. https://doi.org/10.1093/cid/cir695
Ogilvie, G., Knowles, L., Wong, E., Taylor, D., Tigchelaar, J., Brunt, C., James, L., Maginley, J., Jones, H., & Rekart, M.L. (2005). Incorporating a social networking approach to enhance contact tracing in a heterosexual outbreak of syphilis. Sexually Transmitted Infection, 81(2), 124-127. https://doi.org/10.1136/sti.2003.009019
Ottawa Public Health (OPH). (2011). Health Status Report: Sexually Transmitted Infections and Sexual Health in Ottawa. Ottawa Public Health.
Portail VIH/SIDA du Québec (PVSQ). (2016). Peut-on guérir du VIH/SIDA. https://pvsq.org/guérir
Portail VIH/SIDA du Québec (PVSQ). (2016). Quels sont les risques du sexe oral. https://pvsq.org/sexeorale
Public Health Agency of Canada (PHAC). (2011). Report on Sexually Transmitted Infections in Canada: 2011. Public Health Agency of Canada.
Public Health Agency of Canada (PHAC). (2013). The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2013. Infectious Disease-The never-ending Threat-Sexually Transmitted Infections—A Continued Public Health Concern. http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/sti-its-fra.php
Public Health Agency of Canada-2 (PHAC). (2013). The Chief Public Health Officer’s Report on the State of Public Health in Canada, 2013. Infectious Disease-The never-ending Threat-Antimicrobial Resistance-A Shared responsibility. http://www.phac-aspc.gc.ca/cphorsphc-respcacsp/2013/resistance-eng.php
Public Health Agency of Canada (PHAC). (2015). Report on Sexually Transmitted Infections in Canada: 2012. http://www.phac-aspc.gc.ca/sti-its-surv-epi/reprap-2012/sum-som-eng.php
Rowniak, S. (2009). Safe sex fatigue, treatment optimism, and serosorting: new challenges to HIV prevention among men who have sex with men. Journal of the Association of Nurses in AIDS Care, 20(1), 31-38. https://doi.org/10.1016/j.jana.2008.09.006
Santé Montréal. (2015). Les infections transmissibles sexuellement (ITS). https://www.santemontreal.qc.ca/population/sante-de-a-a-z/infections-transmissibles-sexuellement-its/
Santé Publique Outaouais. (n.d.). ITSS : des réponses à vos questions. http://santepubliqueoutaouais.qc.ca/fileadmin/documents/ITSS_Reponses_aux_questions.pdf
Steben, M. et Laberge, C. (Janvier 2006). Les ITSS. Le Médecin du Québec, 41(1), p. 31-67.
World Health Organization (WHO). (2016). La résistance aux antibiotiques oblige à actualiser les recommandations sur le traitement des infections sexuellement transmissibles. http://www.who.int/mediacentre/news/releases/2016/antibiotics-sexual-infections/fr/
World Health Organization (WHO). (2016). Sexually transmitted infections (STIs). WHO: Sexual and Reproductive Health. http://www.who.int/mediacentre/factsheets/fs110/en/