‘This is the way the world ends
Not with a bang but a whimper.’
– T.S. Eliot.

Do you have an apocalyptic vision of the future? An irrational fear that is just plausible enough to give you pause and make you wonder if you’ve worked out what will end humanity? Nuclear war, starvation, climate change, zombie attack; the choices are endless! Maybe it’s just me…

Because I do have an apocalyptic fear. I do have a theory about what might eventually be the death of us all.

Multi-resistant gonorrhoea.

But how can a simple infection cause the end of life as we know it? Draw near, let me catastrophise for you…

First though, let’s talk about the current STI landscape, because that’s terrifying enough! We may be a sex positive and sexually liberated generation but it seems our choices are not without risk.

Working in a London hospital in general medicine, I have to know about sexual illnesses as they are no longer just the domain of sexual health clinics and GPs – these patients are now occasionally requiring hospital care. So much so that I had a teaching session last week on chemsex and the drugs involved, to help me recognise the adverse effects when I see them and know the right questions to ask. The lecturer was rightly keen to emphasise that doctors need to be ‘culturally competent’ to be effective.

This teaching session provided an update on the current rates of STIs around my region of London, throwing around phrases such as ‘syphilis is at the highest rate since WW2’ and showing graphs that plotted a falling line to demonstrate the extraordinary and wonderful improvements in HIV diagnosis rate alongside others that showed an equal rise in diagnosis of other STIs. A Public Health England report for 2017 matches these figures nationally – syphilis diagnoses rose by 20% vs 2016 and an incredible 148% vs 2008; gonorrhoea rose by 22%; and while chlamydia diagnoses fell by 2%, testing has fallen by 61% since 2015 so I’m not sure that counts as a win.

Now, these are facts. But if you would allow me to extrapolate, as I promised I would, I’d like to share my fears. Not of our guaranteed future, clearly, but one that does not feel that far fetched, that unreasonable…

My main worry is that we are no longer afraid of sexually transmitted diseases. Effective treatment, PrEP (pre-exposure prophylaxis) and PEP (post-exposure prophylaxis) have taken the sting out of an HIV diagnosis. Although a stigma may remain, contracting HIV is no longer a death sentence and no longer even implies a lifetime of sex with condoms. We’re not afraid of HIV anymore and all other STIs just need antibiotics, so what’s the harm?

But we should be afraid.

In the era of growing antibiotic resistance, we should be very afraid of a future where treatments no longer work. As we find more cures for big killers, such as cancers and degenerative diseases, infections may well return as the leading cause of death when bacteria become resistant to all available antibiotics. At the moment, there are only a few Super Bugs that have become difficult to treat, but gonorrhoea is one of them.

In March 2018, the first case of multi-drug resistant gonorrhoea was reported in the U.K. It was isolated in a heterosexual man with one regular partner who had had sexual contact with another woman in South East Asia. After the failure of all normal antibiotics, he ended up needing three days of treatment with ertapenem – one of the broadest spectrum and most powerful antibiotics I use in hospital. Two further cases of this strain have been isolated in Australia. This is scary stuff! Due to resistance patterns, gonorrhoea is routinely treated with an injection of ceftriaxone and then azithromycin tablets, already needing a combination treatment, although occasionally the tablets can be used alone. This is it; this is the infection that I have been dreading and it’s already made it to the UK!!

Gonorrhoea is also not just a simple STI. Or perhaps it’s more accurate to say that it isn’t only a simple STI. If an infection is allowed to spread in the blood, it can cause skin or joint lesions and, more concerningly, can infect heart valves causing endocarditis or the brain and spinal cord causing meningitis. While pain on peeing or increased discharge can be pretty fucking awful, these complications of disseminated gonorrhoea can kill. And it is the resistant and virulent strains that are more likely to spread.

So, in your best movie voiceover, in a world that freely has sex without adequate protection; where STI diagnoses are rising; where more and more antibiotics are needed but are less and less effective, does it feel like much of a leap to foresee disaster? What might this future hold? Inpatient wards to treat gonorrhoea like the old TB sanitariums? A return of harmful stigmatisation? Sex once again becoming a fearful and dangerous undertaking? An infertile population as the STIs destroy their reproductive systems? I don’t know, but I am afraid.

Antibiotic resistance isn’t the only reason why I’m deeply (and admittedly perhaps irrationally) afraid of the rise in STIs. I’m also afraid because uptake with testing is still worryingly low and tests are often unfeasibly difficult to obtain. When were you last tested? How often do you do it? Regularly or just when you have symptoms? Also, which tests do you get? Even in areas when STI testing is easily accessible, I do have concerns about the tests that are offered.

(Quick note to non-UK readers – much of what I’m about to talk about involves NHS provision of STI testing and I’m sorry that my knowledge of other country’s services is limited at best, except that I’m almost certain that no country has a perfect system!)

From an apocalyptic perspective, most STI testing is wholly inadequate. In the UK, standard tests check for HIV, syphilis, chlamydia and gonorrhoea but, as with all NHS funded services, the exact testing process depends on local populations and disease prevalence. Is it cost effective to offer thorough testing in a low risk population? Probably not. But will some cases get missed that way? Sure! This is particularly obvious when looking at free postal tests. In London, I can get these standard tests free and easily in the post. In comparison, my parents live in a sleepy village in the countryside – if I still lived with them, I could get a chlamydia test for free but only if I were aged 16-24. In general, it is my experience that attendance in a sexual health clinic would allow me to get tested for those other conditions, but clinics are often difficult and inconvenient to attend. The end result is that we are just not getting tested often enough, and this increases the risk of uncontrollable disease spread.

I also don’t think these standard testing panels are nearly thorough enough. I am particularly amused that they seem to assume that heterosexual couples only have PIV sex, or at least never have sex that doesn’t involve PIV. As described in the SH:24 FAQs, the postal tests offer everyone a blood test for HIV and syphilis but other tests vary depending on sexuality. All men get a urine sample for chlamydia and gonorrhoea, particularly looking for infections in the penis, but only homosexual or bisexual men have anal or oral swabs to check these other places. All women, regardless of sexuality, only get a vaginal swab. Because no women has ever given unprotected oral sex or had anal sex?! And, obviously, all men who have ever had sexual contact with another man will always declare it? Sadly, the rates of STIs do remain significantly higher in gay and bisexual men, exacerbated by risky behaviour associated with chemsex, but whether or not these biases are financially more viable, they seem somewhat naive!

If you follow me or my blog, you’ll know that I adore the NHS and I completely understand how and why funds have to be rationed, but the deficiencies this creates within sexual health provisions bother me. And, of course, feed my fears.

A prime example of this is HPV. I am cynically amused whenever I hear people expressing concern that they have been diagnosed with HPV, asking what this means for their health and whether it is a condition that needs to be disclosed to future partners. I am cynical because I know that these people are not being tested in the UK; HPV testing is not offered on the NHS. There is no treatment for the virus itself, only its effects, and no 100% effective way to prevent its spread other than vaccination, so why spend money on tests? The only circumstance when HPV tests are performed is during a cervical smear and a positive result only effects ongoing management if there is evidence of change within the cells – something that would prompt further action on its own.

‘Ignoring’ HPV in this way feeds into a more personal apocalyptic fear that once caused me to angrily declare myself part of a lost generation! You see, I am old enough that I did not receive an HPV vaccine. As HPV is so prevalent, it was felt that a generalised vaccine programme was not cost effective as anyone who’d already had sex would most likely already have the virus so the vaccine would be wasted. It was saved for girls under 18 as a catch up and is now given to girls aged 12 to try and protect them before they’ve had any sexual contact. Only men who have sex with men are offered the vaccine as it is hoped that vaccinating all women, creating herd immunity, will protect those men who have sex with them. And, knowing what I know about bisexuality and heteroflexibility, I struggle to accept this as a sensible concept. (Although I’m really pleased to hear that I’m not the only one who thinks this is ridiculous and there are calls to extend the vaccine to boys too!)

Again, financially this make might sense but it is galling to be abandoned on the wrong side of the line. The choices about who will and won’t receive the vaccination has created a whole generation of people who should be having shame-free, varied and frequent sex, but who have not been protected from a sexually transmitted virus that can cause cancer. Because it’s too late; we’re likely already infected. We’re lost. Of course, not all HPV strains cause cancer, some just cause warts. And not all cancer-causing viruses actually cause cancer following an infection…but I do wonder if there could be a flood of HPV-related cancers in our future. Cervical cancer screening will catch a lot of them, but HPV has also been implicated in anal and head+neck cancers, for obvious reasons. So yes – afraid and also pretty angry!

I’ve said it before and I’m sure I’ll say it again – ignorance is bliss. (Sorry to ruin that for you!)

Now I’m sure that if trolls find this post, they’ll tell me I deserve cancer for being such a slut – I am literally giving them ammunition for this one – and that we all deserve to become infected and diseased for having sex. Trying to debate rationally with trolls is not often easy (or successful) so I don’t have much of a response, except to tell them not to be so naive! Sex is too much fun for abstinence to work – it’s not a realistic solution. Attitudes such as this are also more than half the problem – the fact that there is this stigma around STIs and that there is always such a horrifyingly vicious response from trolls is exactly why there is such reluctance to get tested. AND, people in monogamous relationships are famously at the same risk of STIs as those in open relationships because people lie. No one is safe.

Instead, we have to find sensible ways to mitigate the risk. Use condoms with casual partners. Get regular tests. Detach STIs from the stigma and shame that surround them. Be aware of the limitations of current tests and ask for what else you want if you have concerns about exposure.

Because I really don’t want to see my vision of the future become reality…

FOR INFORMATION ON TESTS IN THE UK:

Check your eligibility for free HIV tests at test.hiv and other STI tests at freetest.me

Read Lucy Goes Dating’s thread on using a postal STI kit:

I recently discovered that you can order a free NHS sexual health testing kit to do at home.

You can get it from https://t.co/iGMJBmU5Gb

Since I think this is an important subject, here’s my experience of using it.

~THREAD~@NHSEngland @NHSEnglandLDN #sexualhealth pic.twitter.com/eotFGeQ4gr

— Lucy Goes Dating? (@LucyGoesDating) July 7, 2018

And read my post from last year on home HIV testing, with a video demonstrating the test use.

DISCLAIMER: I am a doctor, but I am not a sexual health doctor. I am writing this as a sex-positive woman who understands medical jargon and has enough knowledge to occasionally terrify herself, nothing more than that.