Resistance to antibiotic treatment is making gonorrhea – a common sexually-transmitted infection that can lead to infertility – much more difficult, and sometimes impossible, to treat, which is troublesome, especially in some rural areas of the U.S. where public health officials are reporting dramatic increases in the disease.
The spike is evidenced in this snapshot of rural America:

  • Wyoming experienced a six-fold increase in the rate of gonorrhea infection from 2012 to 2016, said Courtney Smith, communicable disease surveillance program manager for the Wyoming Department of Health.
  • In South Dakota, gonorrhea has increased five-fold statewide over the past decade, according to the South Dakota Department of Health.
  • In North Dakota in 2016, the state recorded 1,005 cases of gonorrhea, almost a 50 percent increase from 2015, according to the North Dakota Department of Health.
  • In 2012, Montana reported 108 confirmed cases of gonorrhea. In 2016, the state reported 864 cases. In Yellowstone County, Montana’s largest county, there were 16 times as many gonorrhea cases in 2016 as there were four years earlier. The number of cases grew from 14 in 2012 to 234 cases in 2016.

The World Health Organization (WHO) attributes the rise in gonorrhea case, at least in part, to increased urbanization and travel. But rural public health and Planned Parenthood officials, those who work in the trenches and who see the infected, have additional theories. They attribute the spike to better, more reliable testing methods coupled with the increased popularity of dating hookup apps that often lead to anonymous sex. They even say what federal health officials seem reluctant to say: There is likely no one single reason for the staggering increases in gonorrhea.

What they do acknowledge is that the alarming increases are pummeling areas that are already vulnerable by virtue of being rural.

RURAL RATES ON THE RISE

Rural residents are more likely to be poor, lack health insurance or rely substantially on Medicaid and Medicare; they also travel longer distances to receive care or to access a range of medical, dental, and mental health specialty services, according to the American Congress of Obstetricians and Gynecologists. Additionally, in 2008, only 6.4 percent of obstetrician–gynecologists practiced in rural settings.

“STDs are an equal opportunity threat – they don’t discriminate based on age, race, socio-economic status or location,” said Dr. Sarah Traxler, medical director of Planned Parenthood Minnesota, North Dakota and South Dakota. “But people living in medically underserved, rural areas are at higher risk because they are more likely to lack health insurance or have a low income and are unable to access basic health care. As we see rates of STDs rising across the country, we should be finding ways to expand access to health care generally – including testing and treatment for STDs – especially in rural areas.”

Condoms, once considered a must-have to guard against STDs and the hallmark of the safe-sex message, are now considered a nuisance and worse. In a national survey conducted by the Kaiser Family Foundation, researchers discovered that:

  • One in six believes that having occasional unprotected sex is “not that big a deal.”
  • 70 percent regard birth control methods other than condoms as “practicing safer sex.”
  • 50 percent regard condoms as a sign of mistrust, infidelity or promiscuity.

Opposition to wearing condoms has become so prevalent that it is commonly referred to as “condom bias” or “condom fatigue.” The terms are used to describe the negative feelings those using condoms have toward them and how tired they are of using them.

A study by Emory University showed that nearly one-third of the men surveyed reported that they have lost an erection after having put on a condom. Given the choice of between maintaining an erection and using a condom, many men are choosing to go without protection, which could be a contributing factor to the rise in gonorrhea cases.

Those who have a bias against using condoms, according to the Emory study, associate condom use with:

  • Lack of sexual spontaneity
  • Unpleasant taste and smell
  • Reduction of sexual pleasure for both men and women
  • Condom use may be seen as a declaration of distrust or infidelity
  • Condom use may be seen as a sign of sexual promiscuity
  • Fear of being identified as “high risk,” or as part of a condemned population such as injecting drug users.

Rural health officials say that while that’s all true, there are still some missing pieces that could help complete the puzzle as to why gonorrhea cases and other STDs are on the upswing.

SEEKING A SOLUTION

Shari Renton, HIV, STD and Viral Hepatitis Surveillance Coordinator for the North Dakota Department of Health, said there are a “number of things” that are likely contributing to the spike.

“I think it’s complicated to really understand why,” Renton said. “Testing technologies have changed over the last decade or longer and with that we have better tools to identify infections. It could be that more providers are actually following testing recommendations more closely and that we may be diagnosing and treating more cases that would have previously gone undetected.”

The increased popularity of sexual “hookups” is also likely playing a role, Renton said.
“We know that many people are having more anonymous sex or sex with people they don’t know the names of, so it’s hard to make referrals to get these individuals in and tested which can lead to more spread of the infection in the community,” Renton said.

Moreover, she said, though funding has not been reduced or clinics closed, there is definitely a barrier to access. “We do not have STD clinics and some of the local public health units do not offer STD services. We do have many other places for individuals to go to receive services, yet access and utilization of clinics due to being affordable, are issues that curb people accessing care for a number of things, not just STDs.”

Derrick Haskins, communications director for the South Dakota Department of Health, echoed Renton’s sentiments. He said while there are many possible reasons for the increase, “a risk factor we seem to be seeing more often is the use of hook-up apps such as Grindr and Tinder.” Grindr is a geosocial networking app geared towards gay and bisexual men, designed to help them meet other men in their area.

In Montana, Planned Parenthood has seen an increase in positive gonorrhea cases in its patients, especially in people 24 years old and under, said Jill Baker, director of Learning for Planned Parenthood of Montana.

This increase is likely due to multiple factors. Under the Affordable Care Act and Montana HELP program, more people have health coverage to access preventative screenings during routine exams.

“While screening has increased, there is still much stigma and privacy concerns for young people accessing preventative measures like condoms,” Baker said. “This is especially true in rural areas where it is very likely that a young person will personally know the local health care provider and pharmacist and worry about their confidentiality. These confidentiality concerns may be real or perceived, but still remain a barrier to access.”

In addition, access to accurate information about reproductive and sexual health is dismal at best for young people in the state, Baker said. Often parents and teens both feel ill-equipped and embarrassed to bring up the subject. In addition, only 22.6 percent of schools teach all 19 HIV, STI, and pregnancy prevention topics recommended by the state. Teachers are also ill prepared to teach on sexual health topics.

More than 800,000 people in the United States are estimated to get gonorrhea infections each year and more than half of those infections go undetected, according to the Centers for Disease Control and Prevention (CDC). People get gonorrhea by having vaginal, anal or oral sex with someone who has the disease.

“The increase in gonorrheal infections in Yellowstone County is particularly worrisome because the disease has become increasingly resistant to the antibiotics used to treat it,” said Tamalee St. James, RiverStone Health Director of Community Health Services and Deputy Health Officer for Yellowstone County.

Health care providers across the country share the concern.

Ten years ago, the CDC recommended five antibiotic treatment options for gonorrhea. Only one recommended option remains, a combination of two antibiotics given together. Antibiotic resistance led the CDC to list gonorrhea as one of the three most urgent drug-resistant threats.

Left untreated, gonorrhea can cause serious health problems, including chronic pelvic pain, life-threatening ectopic pregnancy, and infertility in women. In men, untreated gonorrhea can lead to a painful condition in the tubes leading to the testicles. Having the infection also increases the risk of getting and transmitting HIV.

The medical community desperately needs new antibiotics to treat gonorrhea and longer-term a vaccine to prevent it, according to the WHO.

Until then, the best approach is prevention, according to public health officials. Consistent and correct condom use, and limiting the number of sex partners, can help reduce the risk of gonorrhea and other sexually transmitted diseases. Anyone who is sexually active should discuss risk factors and testing with a health care provider.

While symptoms of gonorrhea may include discharge and pain during urination, often people have no symptoms, according to the WHO.

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Cindy Uken
Cindy Uken is a veteran, award-winning health writer living in Palm Springs. She has worked at newspapers in California, South Dakota, Minnesota, Montana and at USA Today. Cindy received a 2013-2014 Rosalynn Carter Fellowship for Mental Health Journalism, chosen as one of the California Endowment Health Journalism Fellowships, inducted into the Yankton (S.D.) High School Fine Arts Hall of Fame, nominated for a Pulitzer Prize for her work on Montana’s suicide rate, and named one of Gannett’s Top Ten Supervisors of the Year. Follow Cindy on Twitter @CindyUken, on Facebook and at CindyUken.com.