Alberta’s STI levels made headlines this spring, when the province’s chief medical officer, Karen Grimsrud, said rates were at “epidemic proportions.” She blamed the rise of dating apps. But is swiping right really behind the increase?
Gonorrhea, chlamydia and syphilis rates across Canada have been rising steadily since the late 1990s, and recent spikes are “extremely concerning,” says Doug Sider, chief of communicable diseases at Public Health Ontario. In 2013, Canada’s chlamydia rates reached 296/100,000 and 3,266 cases of syphilis were reported — among the highest numbers in over a decade. And in Alberta alone, gonorrhea jumped from under 2,000 cases in 2013 to 3,400 at the end of 2015. This was in addition to increases in normally negligible rates of STIs like lymphogranuloma venerium, which carries greater health risks and is harder to treat.
While apps that facilitate hook-ups might be helping to fuel this trend, online dating isn’t the only factor. Other contributors include inadequate testing for STIs and people nixing condom use.
“It’s a lot easier to take a phone, swipe and hook up than it is to walk into a bar and find someone to take home,” says Lyba Spring, a sexual health educator who spent 30 years working with Toronto Public Health. “But we can’t blame the apps for unsafe sexual practices.”
The Tinder effect: more partners, less information
Tinder, Grindr and other dating apps are wildly popular, with Tinder producing an average of 26 million matches per day worldwide. Both are frequently used to arrange first dates and to connect with other users looking for casual sex. And Gerry Predy, senior medical officer at Alberta Health Services, argues they’ve played a primary role in Alberta’s STI increase.
Using the apps makes it easy to have casual sex with multiple partners who are near strangers. And “if you don’t know who you’re having sex with, you better be sure you’re using protection,” says Predy.
Another concern is that increasingly, the only contact information patients have for their sexual partners is a profile on an app or website, says Predy. Plus, privacy policies at Tinder and Grindr prevent them from distributing personal information to third parties. Anonymity makes it hard for public health units to contact the previous sexual partners of someone who tests positive for an STI. That’s important, because STIs often have no symptoms, so people may not know they are infected and continue to have unprotected sex with others.
Reduced safe-sex practices
Usually, public health units can count on certain trends in STIs. Infections are more common in urban areas, and tend to be higher in certain populations, including young adults, sex workers, and men who have sex with men (MSM). But the recent increases challenge this conventional wisdom. “We’re seeing much higher rates throughout the province and in a much higher age range,” says Vanessa Allen, chief of medical microbiology at Public Health Ontario.
And although there is growing concern around multi-drug-resistant gonorrhea, the spike is across all STIs, so changes in sexual behaviour provide the only explanation. “There’s a change in either concern about getting these infections or the practice of using protection,” says Allen.
Some people are now simply less concerned about getting STIs or HIV, says Spring. “Because HIV is now a chronic manageable disease, it is no longer considered the end of the world.” But the daily medication and reduced lifespan associated with HIV means it’s still a serious diagnosis. And, says Spring, “HIV is not the only game in town.” Though some STIs can be resolved with early detection and treatment, Allen stresses that they are not “benign illnesses.” If untreated, gonorrhea and chlamydia can cause infertility, while syphilis causes neurological and cardiovascular complications.
But different subgroups may need different kinds of interventions. “It may not be a one-size-fits-all explanation,” says Sider. He points to the MSM community as an example, where specific factors might be leading to decreased condom use, including advances in treatment and prevention for HIV, such as transmission risk-reduction drugs like PrEP, and the practice of choosing sexual partners with the same HIV status.
Those in their early 20s may be becoming more blasé about safer-sex practices, compared to their teenage counterparts. In 2009/2010, 68% of sexually active people aged 15 to 25 reported using condoms the last time they had sex, compared to 62% per cent in 2003. However, within that age group, condom use declined with age. The report showed young adults tended to drop condoms in favour of other birth control methods, like the pill, particularly when they were in monogamous relationships. Monogamy often doesn’t offer the protection many hope because serial monogamy is common among young adults, and both partners don’t typically go for testing before beginning a new relationship. Meanwhile, relationships thought to be monogamous may in fact not be.
Other research indicates the next wave of safer sex education may need to aim way older – at their parents. Between 1997 and 2007, chlamydia rates in adults 40 to 59 increased by 166%. A 2016 study found that fewer middle-aged men and women used condoms during their last “hook-up or one night stand” compared to university students, which researchers suggest may be because they don’t have the same concerns about pregnancy or have outdated information about safer-sex practices and the risks for STIs.
Is chlamydia and gonorrhea screening falling through the cracks?
Some also question whether the shift away from annual physicals and reduced frequency of Pap tests may have unintentionally led to less STI screening. Later identification or missed diagnoses of STIs mean STIs go untreated and continue to spread.
A Toronto study looked at the impact of the 2012 changes to cervical cancer screening guidelines, which recommended screening start at age 21, as opposed to within three years of the onset of sexual activity and reduced the frequency of PAP testing from every year to every three years. The study involved two random groups of 100 19-to-25-year-old women (taken before and after the policy change). In the year before the policy change, 42% of the women underwent Pap testing and 40% were screened for chlamydia and gonorrhea. One and a half years after the updated recommendation, 17% of women underwent Pap testing and only 20% were screened for the two STIs.
“Historically, the PAP test was very much linked to screening for STIs,” says Tali Bogler, a family physician at St. Michael’s Hospital and the study’s lead researcher. She says the PAP was one of the few reasons that brought healthy young women into her office.
Michelle Greiver, a family physician with the North York Family Health Team, has had similar experiences in her practice. She says discussing sexual health and screening sometimes falls off the radar because the visits focus on urgent issues. She suggests electronic medical record (EMR) alerts might be part of the solution.
“If you’re someone who’s 50 or older and you come in for a cold, there’s an EMR alert that tells me if you’re due for a fecal occult blood test, but there’s nothing set up to remind us of [STI] screening for those at risk,” says Greiver.
Choosing Wisely Canada, which supports the new recommendations around annual physicals and PAP tests, still recommends that appropriate preventative screening, including STI testing, be done when a patient is at risk. The Public Health Agency of Canada offers information for doctors about how to evaluate a patient’s risk for STIs. Risk informs screening frequency and can include things like drug use, types of sexual activity, and relationship problems. The Agency recommends that doctors discuss sexual health with patients annually to assess the need for screening, which for high-risk individuals can be as frequent as every three months.
Changing approaches to counter rising rates of gonorrhea, chlamydia and syphilis
In light of her own research findings, Bogler has changed the way she approaches sexual health with her patients. “I do find myself asking about sexually transmitted infections and offering screening at really any encounter with my patients,” she says.
That’s the approach Alberta Health Services wants its physicians to use: to frequently discuss screening with sexually active patients— and re-screen anyone who discloses having new or multiple sexual partners. Allen adds that conversations between clinicians and patients about sexual behaviour should be specific and frank. “An individual can have a [sexually-transmitted] infection of the throat without having an infection at other sites, so just relying on cervical screening or urine screening might not be accurate,” she explains.
Empowering patients is key, according to Spring. “The education piece is necessary in order to help people understand what infections they need to be tested for and how to ask for testing,” she says. And reaching them is crucial to promoting safer-sex behaviours. Alberta Health Services has taken its outreach online, advertising on websites frequented by high-risk populations and creating sexgerms.com (featuring STI jokes and articles like “Junk Protection 101”).
As a start, says Predy, everyone should reflect on their STI risk level. “We just want people to be aware that even if they don’t have symptoms, if they are engaging in sexual activity, particularly high-risk, they should be getting tested regularly,” he says.
In the end, they’re hoping a multifaceted approach will limit the rise. “There’s not a single magic bullet to eliminating the results of unsafe sexual practices,” says Spring. “You need a full chamber.”