Image credit: Reginald Mount, ‘The easy girlfriend’ (poster), Norwich: Her Majesty’s Stationery Office, 1943-44. This file comes from Wellcome Images, a website operated by Wellcome Trust, a global charitable foundation based in the United Kingdom. Refer to Wellcome blog post (archive).
Two or three times a year, there’ll be a major conference on sexual health, or a report released on how many new sexually transmitted infections – STI for short – were diagnosed in the previous year. Usually there’s an up-tick in something and media coverage follows like, well, clockwork. Just as predictable are the narratives invoked to contextualise the findings. A recent article by Aisha Dow is a case in point: along with online dating and hookup apps, the article suggests that ‘complacency as a result of improvements to HIV treatment, decreased condom use and more young people travelling overseas could also play a part.’
For a long time I assumed the clinicians and epidemiologists offering these explanations were playing out a cunning media strategy. Now, I’ve come to believe they just don’t read any social research. They offer journalists the same explanations they themselves have read in the newspapers – contributing to an unchecked epidemic of bullshit.
Effective HIV treatments were introduced twenty-two years ago. Tinder was launched in September 2012, while OkCupid has been around since 2002. (Getting smashed and hooking up with a nearby stranger, however, dates back to the Neolithic at least – 12,000 years, give or take.) These are very longstanding trends and as such, they are not good candidates as likely causes of this year’s increase in STI figures.
However, these condensed narratives constitute the popular folklore of sexual health – the cultural framework through which we understand the pathogenic sequelae of getting it on. Overwhelmingly, these explanations focus on individual behaviour and technology-mediated social change.
Prof Marcus Chen, a clinician at the Melbourne Sexual Health Centre, says in Dow’s piece: ‘We don’t know the precise drivers, but there may be an increase in sexual risk. We know anecdotally that a lot of people are meeting online (and) finding sex partners online.’ And from Dr Bill Boyd, quoted in The Age last year: ‘STI transmission is entirely down to human behaviour and people need to think twice when using dating apps for hook-ups.’
"For a long time I assumed the clinicians and epidemiologists offering these explanations were playing out a cunning media strategy. Now, I’ve come to believe they just don’t read any social research."
This coverage often focuses on the emergence of antibiotic-resistant STI, invariably described as ‘superbugs’, or even ‘super-superbugs’. In one recent piece Prof John Turnidge was quoted saying that this ‘leaves patients with no effective treatment options and aids the spread of the sexually transmitted infection.’
This prompted Dr Brad McKay, host of the TV series Embarrassing Bodies, to declare super-superbugs ‘bacteria that are able to survive any antibiotic known to mankind.’ (Perhaps a reason to see a female doctor?) I asked an infectious diseases specialist if McKay was correct. In fact, it means that ‘frontline’ and ‘second-line’ treatments don’t work, so older medications with more serious potential side effects must be prescribed under specialist supervision.
McKay concluded that, ‘For sexually active Australians, this means it’s even more important to use barrier protection.’ As clinicians engage with the media on sexual health, there is an implicit and sometimes explicit strategy of presenting antibiotic resistance as a reason to continue using condoms, at a time when the Pill is available for women and PrEP can protect people who are otherwise at risk of HIV.
In this coverage, messages on sexual health almost invariably focus on sex rather than health. Increases in diagnoses are explained as driven by changes in sexual behaviour, and calls are made for individuals to make better choices around sex. However, the second round of ASHR – a major population study of sexual health – found only 13 per cent of heterosexual men and 17 per cent of women reported having a sexual health check in the last twelve months. A survey by Men’s Health magazine in 2011 found 42 per cent of their readers had never had a sexual health checkup. (From this great confessional piece by Simon White, which is illustrated with a picture of a muscular black man, because racism.)
This is where the wheels begin to fall off the individualising explanations. The ASHR study found sexual health knowledge and awareness have improved since the first wave of the survey in 2002; this may reflect national campaigns that declared ‘STIs are spreading fast.’ However, many heterosexuals remain unaware that you can have an STI without any symptoms. If I go to a doctor and say ‘I’m a gay man’, I get a sexual health checkup, no questions asked. If a heterosexual mate sees their local GP and asks for the same, they often get asked why. The surgery becomes the confessional – and the wages of sin is purulent discharge.
"Apart from sex workers, very few people use condoms for oral sex, which can transmit gonorrhea. So, condoms are not a comprehensive option for primary prevention of STI..."
Media coverage of STI figures also tends to assume that diagnoses reflect incidence. In other words, that a case diagnosed in 2017 reflects a new infection acquired in the same year, so that the number of diagnoses must track changes in sexual culture and practice. In fact, there can be a substantial delay between infection and diagnosis, and this creates a pool of undiagnosed cases who can pass on infection. As that pool increases in size, so does the rate of new infections – that’s what defines an epidemic. Above a certain point, the epidemic becomes self-sustaining, like a nuclear reaction achieving criticality.
The control rods, in this admittedly vivid metaphor, are regular testing and treatment for STI. The emphasis on individual behaviour obscures the reality that STI rates are predominantly driven by testing frequency and access to convenient, non-judgmental sexual healthcare. For example, when the Campbell Newman Government in Queensland cut funding to sexual health services, they were unable to curb an emerging epidemic of syphilis, which has now spread across the state in communities that already struggle with access to culturally safe healthcare. (A piece by Michael Koziols on that epidemic is a model for how to write an informative and sensitive ‘STI rates are increasing’ story.)
A while back I wrote about the game-changing new prevention drug, known as ‘PrEP’ (pre-exposure prophylaxis). My editor just couldn’t believe I didn’t mention STI risk when condoms are not used. In fact, like herpes (and HPV in unvaccinated people), syphilis mainly spreads via skin-to-skin contact with parts of the body a condom may not cover. Apart from sex workers, very few people use condoms for oral sex, which can transmit gonorrhea. So, condoms are not a comprehensive option for primary prevention of STI – that is, the steps a person can take to avoid getting one in the first place.
For that piece on PrEP, I wound up writing a sidebar explaining that gay men’s education has never focused on primary prevention. Rather, we encourage regular testing and prompt treatment to remove people from the infectious ‘pool’. This ‘test-and-treat’ strategy is primary prevention for that person’s future partners. Regular testing – not behaviour change – is the key message on STI for all sexually active people in Australia.
If we test more people more often, we can expect to see diagnoses increase – and that’s why it’s important that diagnoses are not treated as a straightforward measure of the success of our sexual health strategy. But that’s a big ‘if’ – in my home state, the sexual health centre is a single location offering conveyor-belt service, triaging clients according to broad risk groups and self-reported symptoms. This creaky infrastructure could never support the clinical load that would result from a widespread increase in regular checkups. This is the barrier that drives STI rates skywards – not hookup apps and complacency.
Daniel Reeders is a PhD candidate at the ANU School of Regulation and Governance, where he is studying the role communities play in health promotion. He writes a blog, Bad Blood, about stigma, culture and health.