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Sex on Wednesdays | Ancient Alliteration

Syphilis: Spectacularly Sisyphean

by Martha Kempner 

When my husband and I got married in 2002, Massachusetts required us to get tested for syphilis.

Our shared primary care doctor—a nice cardiologist with a stutter whom we called Henry, though not to his face—was shocked by our request as New York did not have the same pre-marital requirement. He mused that he couldn’t remember the last time he’d tested anyone for that particular STD. (By 2002, even older cardiologists had stop using the term VD, but changing from disease to infection was still a ways off.)

At the time, the only people who had syphilis were men who had sex with men, and same-sex marriage was not yet legal even in Massachusetts. I thought asking us to test was funny and possibly ironic in an Alanis Morisessian kind of way. (It did rain on our wedding day, btw.)

In 2000 the CDC was engaged in a Syphilis Elimination Plan. Fewer than 6,000 cases were reported, and rates had fallen 89% over the previous decade to just 2.2. cases per 100,000 people. The U.S. was all but ready to declare victory over the disease that had killed Al Capone, Oscar Wilde, and Edouard Manet. (Thanks, Amy.)

Anyone who read headlines this week knows this didn’t go as planned. Syphilis is not gone. Indeed, it’s booming. According to newly released STI data, syphilis rates are at their highest since the 1950s and show no signs of letting up. In 2022 there were 207,255 cases of syphilis in the U.S. for a rate of 495 cases per 100,000 people. Men who have sex with men are still disproportionately affected. Cases of primary & secondary (P&S) syphilis in this group rose by 4% between 2021 and 2022. They are no longer alone, however, as cases of P&S syphilis rose 19.2% among women during that time.

The increase in syphilis among women has led to an alarming rise in congenital syphilis—babies born with the infection. In 2022, there were 3,755 cases of congenital syphilis reported, including 282 congenital syphilis-related stillbirths and infant deaths. As some experts have noted, each case of congenital syphilis is a failure of both STI prevention/treatment and prenatal care. (While I wouldn’t have had to get tested for syphilis if I’d gotten married in New York, I had my first baby there, and I think I was tested three times before delivery.)

A Spotty History of Syphilis (Pun Intended)

Syphilis has been around forever. Really. There are many theories about where it came from and how it spread through Europe (turns out it was not Columbus’s fault), but there is agreement that it began spreading at a rapid clip between the 12th and 14th centuries.

Italian physicians who treated soldiers during a 1495 battle with French troops said the enemy had pustules “more terrifying than leprosy and elephantiasis.” They believed the disease was sexually transmitted in part because the French army was known for its drunken debauchery. The infection got its name from a three-book series written in 1530, “Syphilis sive Morbus Gallicus,” about a character who was cursed with a hideous disease after refusing to worship the god Apollo. In the 1600s some people blamed syphilis on sex between a Spanish prostitute and a French leper. In 1767 a famous doctor of venereal diseases did a study in which he took the discharge from the urethra of a man suffering from gonorrhea and put it into a healthy man. The healthy man got syphilis, and the doctor concluded gonorrhea caused syphilis. That’s not how it f**king works—the first guy clearly had both STIs.

It wasn’t until the 1940s that science had identified the cause of syphilis and developed a test that could distinguish it from other infections. That decade also brought us penicillin which finally provided a cure for the disease.

Modern history of syphilis in the U.S. is forever tainted by the Tuskegee Study which violated every tenet of ethical research and basic human decency. In 1932 the U.S. government recruited Black men and promised them health care in exchange for participation in a study. Many of the men had latent syphilis, but the researchers never told them. Worse, researchers withheld treatment even after penicillin was invented in order to keep studying the men. The study was supposed to last 6 months; it ended in 1972.

It’s A Dick Disease That Makes You Nuts

Syphilis is an infection caused by the bacteria Treponema pallidum. It is passed through direct contact with sores (called chancres) that can occur in, on, or around the penis, vagina, anus, rectum, or lips/mouth. There are four stages of the disease.

The primary stage starts with the appearance of one or more sores that are usually hard, round, and painless. These sores will go away in three to six weeks with or without treatment. If not treated, syphilis progresses to the secondary stage which usually starts with a rash and possibly more sores. People may also have flu-like symptoms such as fever, swollen lymph nodes, headaches, and a sore throat. For obvious reasons, these symptoms are often mistaken for other health issues. The sores and symptoms will also go away even without treatment. Primary & Secondary (P&S) syphilis are the most contagious stages of the infection.

Syphilis then enters its latent stage where it lies dormant in the body for months or years. If left untreated it can lead to tertiary syphilis which is rare and can appear 10 to 30 years after a person gets infected. It can affect the brain, nerves, eyes, heart, or joints. Symptoms vary depending on the organs affected, but this is where we get the stories of people who went blind, deaf, or “crazy” from the disease.

I’ve always loved the theory that Donald Trump’s inability to put together a sentence comes from untreated syphilis. I mean, he’s bragged about his conquests and about not using condoms in the past, but back then he could at least construct a proper sentence. Now, not so much. The disease can cause trouble focusing, confusion, personality changes, memory issues, and difficulty thinking and making decisions. It fits. (It’s also entirely speculation, but by his rules it’s fine to speculate or lie as long as I start the sentence with “people are saying.” Let’s pretend I did that.)

Condoms Are So Last Century

What I’ve found interesting is that condoms have been completely absent from this most recent discussion of soaring syphilis rates. Condoms were the centerpiece of public health messaging in the 80s, 90s, and 2000s when there were few other options to protect sexually active people against HIV.

While condoms don’t offer perfect protection against syphilis because sores can appear in areas that not covered (like on the scrotum), they certainly reduce the risk of transmission. The timeline of increasing emphasis on condoms and dropping rates of syphilis pre-2000 line up. The timeline of decreasing emphasis on condoms and increasing syphilis rates also line up.

And yet, I’m reluctant to even mention condoms because the whole concept of telling people to use them feels dated. In many ways, HIV prevention has moved beyond the condom because of scientific advancements. Today’s treatments are so good that people with HIV can have undetectable viral loads. People with undetectable viral loads can’t transmit the virus sexually. For people who don’t have HIV, PrEP—pre-exposure prophylaxis—reduces the chance of getting the virus from sex by 99% if taken correctly.

It is possible that Doxy-Pep—a new strategy of preemptively using doxycycline to prevent gonorrhea, chlamydia, and syphilis—will do the same thing for other STIs, but we’re not there yet.

At this point our best prevention methods remain widespread screening and treatment. You have to know you have syphilis in order to treat it, and you have to treat syphilis in order not to spread it to someone else.

Unfortunately, screening and treatment efforts are not reaching some of the groups that are most affected including young people (ages 15 to 24), gay and bisexual men, and pregnant people. The most recent data also showed that rates among American Indian and Alaskan Natives were disturbingly high. Rates of P&S syphilis in this group are at pre-penicillin level. Rates of congenital syphilis are also alarmingly high; for every 155 American Indian and Alaska Native births in 2022, there was one case of congenital syphilis.

As the CDC points out, these disparities are not explained by behavior. Instead, they reflect other inequities in our society such as poverty and a lack of access to quality health care.

Ivan the Terrible and Beethoven Have Been Dead for a Long Time

In researching for this article, I learned that syphilis was nearly eliminated in 1957, but rates rebounded. That pattern of near-elimination and rebound repeated itself every seven to 10 years though 2000.

Oddly enough this makes me feel better. It’s not that we got super close and failed. It’s that the bacteria that plagued Ivan the Terrible (and maybe Trump the Terrible) was never going anywhere.

Addressing syphilis is a Sisyphean task. We might not ever clear the mountain, but we can reduce the spread of the infection, mitigate the damage it causes, and address the staggering health inequities in our country. And maybe, just maybe, remind people that condoms aren’t terrible. (Yes, I said it. And I know I sound like an out-of-touch old lady. It’s okay. My kids have made sure that I know exactly how old and out of touch I am.)

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