As we creep back toward normal, what should we do about the rise of sexually transmitted infections?
By Peggy Orenstein and Ina Park
Dr. Hilary Reno’s eyes widened as she scanned the waiting room at the St. Louis County Sexual Health Clinic in Missouri, where she’s the medical director. She was used to seeing a swath of humanity parked in those plastic chairs: middle-aged men secretly screening after a tryst; college students making a post-hookup pit stop; teenagers, fresh in love, testing together before taking the next step. But now, in the spring of 2019, every seat was filled, with more patients leaning up against the walls. “How,” she thought to herself, “can we possibly keep up?”
This week, in its annual S.T.D. Surveillance Report, the Centers for Disease Control and Prevention confirmed what physicians like Dr. Reno already suspected: that 2019, the most recent year for which data was collected, would set a record for reported cases of sexually transmitted infections. In 2018, an estimated one in five Americans had an S.T.I.; that’s about 68 million people. At least 26 million new infections were contracted during 2019 alone. Chlamydia hit an all-time peak — St. Louis, as it happens, has historically led U.S. cities in cases — while gonorrhea and syphilis, along with congenital infections and newborn deaths, were at their highest rates since the early 1990s. The trends for syphilis are particularly striking, given that two decades ago, it was close to elimination.
For a while, it appeared that the pandemic lockdown might unintentionally ease the surging S.T.I. epidemic. While a few holdouts chose to manage their anxiety through sex with strangers rather than stress baking, most people hunkered down, socially and sexually distancing. And it wasn’t just Americans. Studies from Britain, Asia and Australia also found that Covid-19 dampened people’s sexual ardor: About 40 to 60 percent of adults reduced their number of partners; a similar percentage reduced the frequency of sex or abstained altogether. Instead, like everything from cocktail hours to corporate meetings, hookups went online. Tinder saw a record 3 billion swipes on a single day last March. Likewise, from March through May, OkCupid recorded a 700 percent increase in virtual dates.
But fear of contagion and death will depress libido for only so long. Just when quarantine fatigue began eroding sexual restraint, the urgent needs of Covid-19 gutted the country’s fragile infrastructure for S.T.I. control. Two-thirds of public sexual health clinics were forced to cut back their services or shut their doors in 2020, their staffs redeployed to the Covid-19 response — only one of New York City’s eight clinics remained open during the early months of the pandemic. Screenings were eliminated, follow-up of patients and their sex partners reduced.
Contract tracers, too, were reassigned to track coronavirus transmission, so attempts to reconstruct sexual networks — a major tool in reducing the spread of S.T.I.s — plummeted. The result? Delays in diagnosis, scarce access to treatment and the likelihood that we’ll keep racking up those astronomical transmission records, albeit without the same ability to document that it’s happening.
Infection rates are up across lines of race, gender and age (rates among the elderly have notoriously spiked in recent years), influenced in part by drug use, poverty, unstable housing and stigma. The C.D.C. has also cited decreased condom use, especially among gay and bisexual men and young people in general: Over half of new cases in the current report occurred among 15-to-24-year-olds. In fact, it’s one of the arenas in which our country truly excels — We’re No. 1! We’re No. 1! — at least among developed nations in rates of S.T.I.s.
It’s hard to imagine that status changing as the under-25 set is sprung from its Covid captivity. Recall that after the 1918 Spanish flu pandemic, the ’20s roared as a generation made up, Gatsby-like, for lost time. Nicholas Christakis, a physician and a professor of sociology at Yale, has already predicted a possible uptick in what he called “sexual licentiousness” by 2024. We wouldn’t be quite so judgy, and what’s more, partying never fully stopped during the pandemic. (Many college campuses were virus hot spots.) Still, it’s certainly plausible that once the masks come off, 21st-century youth will try to compensate for what they’ve missed by doubling down on party and hookup culture.
Their year of relative isolation has meant that much less practice with face-to-face communication, including negotiating intimate encounters and prioritizing safety. Nor, according to Lisa Wade, an associate professor of sociology at Tulane University who has interviewed over a hundred students on sexual behavior during the pandemic, are young adults grasping the connections between the questions they ask to avoid Covid and those they ought to be asking to protect their sexual health. What’s more, she found, even as they’re “extraordinarily compliant” about wearing masks, many do not use condoms, including those with multiple partners.
Those students may be singularly ill prepared to deal with the inevitable aftermath — how could they be, when we’ve failed to do what reputable studies have suggested for decades: provide them with high-quality sex education. That is exactly the solution proposed by the Department of Health and Human Services last year when it issued its first-ever S.T.I. National Strategic Plan for 2021-25. Among the main objectives is to support “a nonstigmatizing, comprehensive approach to sexual health education and sexual well-being, especially in adolescents and young adults.”
Sounds reasonable, right? Yet sex education in this country is still one of the most divisive of issues, ground zero of the culture wars. During that postpandemic heyday of the 1920s, crusaders for contraception were threatened with fines and imprisonment under Comstock laws that labeled their instructional pamphlets as both obscene and encouraging promiscuity. By the 1970s, after the pill and legalized abortion decoupled sex from reproduction — making the notion of waiting until marriage, or even adulthood, obsolete — sex ed became a vector for conservatives’ anxiety about the erosion of traditional matrimony, the rise of women’s rights, the growing acceptance of homosexuality, the potential dismantling of gender itself. In 1979, the Rev. Jerry Falwell created the Moral Majority, a forerunner of today’s far right, in part to combat sex education, which he claimed was “Soviet propaganda.”
That organization was widely credited with helping deliver the presidency to Ronald Reagan. Two years later, Mr. Reagan signed the first law funding programs that promoted abstinence until marriage as the expected standard. More than $2 billion has since been shoveled into the maw of abstinence-only education (more recently rebranded “sexual risk avoidance” education), mostly funding programs that have been proved ineffectual at either delaying vaginal intercourse or reducing risky sexual behavior. You know what does both? Curriculums that are not only comprehensive but also pleasure-based: built on the premise that sexual activity should feel good for everyone involved, rather than casting it as inherently dangerous or wrong.
We get that everyone is sick of hearing about the Dutch, but their version of sexuality education remains the ideal. It starts in kindergarten, though at that age the conversation is about friendship, family and love, not sex. As they progress, students learn about anatomy, reproduction disease prevention, contraception and consent; they also discuss relationships, masturbation, oral sex, orgasm, gender identity and same-sex encounters. (Openly addressing gay sex practices is especially important to avoid marginalization and to reduce the disproportionate S.T.I. rates among men who have sex with men.) Not only do young Dutch women — controlling for demographic differences — report feeling happier than Americans with their early experience, but those who have vaginal intercourse do so later, have fewer partners and are exponentially safer. The rate of gonorrhea among Dutch teenagers in 2006, for instance, was about 14 per 100,000 adolescents, compared with our nearly 459. Their rate of chlamydia was about 150 per 100,000 adolescents; ours was nearly 2,863.
In this country, 39 states and the District of Columbia mandate some form of sex education; 18 dictate that such classes be medically accurate. Maine is the sole state requiring schools to teach actual skills in both communication and “responsible decision-making regarding sexuality.” We’re sure those enlightened Mainers do their best, but it’s really too much to ask for them to be responsible for changing how young people nationwide navigate their sexual relationships.
As for the rest? They’re left to their own devices — literally. A nationally representative survey released in January found that among 18-to-24-year-olds, the most-cited “helpful source of information about how to have sex” with a partner was online pornography. That came out ahead of actually talking to your partner, especially among young men. Now imagine the Venn diagram of that report and the C.D.C. data on the same age group.
Obviously, President Donald Trump was never going to enact his own agency’s S.T.I. plan; his 2021 budget proposal included $75 million funding for those debunked sexual risk avoidance programs while eliminating all evidence-based teenage pregnancy prevention efforts. But maybe the Biden administration will do better, especially given its pledge to revisit its predecessor’s regulations on campus sexual misconduct: Among its other benefits, comprehensive sex education, when combined with instruction in refusal skills, appears to be significantly protective against assault in college.
Once the pandemic is finally behind us, Covid-driven funding for health department infrastructure and contact tracers should be maintained and redirected toward creating robust S.T.I. control programs in every state, including expanding access to publicly funded sexual health services. All of that would be politically contentious, but the alternative is to continue to sacrifice the health of tens of millions of young people: Untreated S.T.I.s can result in pelvic inflammatory disease, infertility and cancer, and increase the risk of acquiring and transmitting H.I.V.
As vice president, Joe Biden helped initiate the It’s on Us campaign, aimed at reducing sexual assault. The administration’s next step should be, again, to reject the politicization of what is, in fact, an urgent health issue (especially in the era of internet access and hookup apps), cast off four decades of damaging abstinence-centered curriculums and adopt a proven, enlightened approach to young people’s education: one that is not exclusively focused on risk and danger, that promotes healthy sexual development and relationships — so we can ensure that, if they do choose to engage, they do so safely, responsibly, ethically and joyfully.
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