Earlier this month, public health officials warned of a syphilis outbreak in Houston, with cases jumping 57 percent between 2019 and 2022. Syphilis is a bacterial infection spread by sexual contact. The outbreak mirrored a national trend in which sexually transmitted infections (STIs), such as chlamydia, gonorrhea and syphilis, are all sharply rising. More than 2.5 million cases of chlamydia, gonorrhea and syphilis were reported in 2021.
Experts like Dr. Allen Ghareeb, a maternal-fetal medicine fellow based in Washington, tells Salon there are many reasons why STIs are on the rise. For one, like many suspected, the COVID-19 pandemic kept people out of routine care, particularly when it came to sexual and reproductive health. Because many STIs can be asymptomatic, a lack of routine checkups proved to exacerbate the already worrisome trend.
Compounded with the ongoing shame and stigma attached to getting tested or having an STI, the rise in infections makes some sense. However, an overall decline in condom use is partly to blame for the trend as well. This is puzzling given that reproductive rights are regressing and STD rates are rising. One would expect contraceptive options like condoms to be flying off shelves — but they're not.
"Condom use has declined — and it's not trivial by any means," Ghareeb said. "Over the last couple of years, obviously, a lot of the attention in reproductive health care has been diverted to other issues and important issues, but I think we need to kind of refocus some efforts on those safe sex practices."
According to a survey published by the Department of Health and Human Services, men's condom use declined from 75% in 2011 — being the top contraceptive option — to 42% in 2021. While a promising market analysis showed that condom sales increased by 23.4% between February and mid-April of 2021 compared to the same time in 2020, that increase could simply have been attributed to a rebound from the pandemic. Overall, the trending drop of condom use is worrisome amid an STI epidemic after years of maintaining a strong foothold in the United States's contraceptive market. In 1998, researchers hailed that condom use was in fact on the rise. What gives?
The decline of condoms
Gigi Engle, a certified sex educator and lead intimacy expert at 3Fun, said she suspects condom use is declining for a few reasons. First, it could be due to inadequate sex education in schools, particularly in states where abortion bans are taking place like Texas and Idaho. As Guttmacher Institute found, adolescents between 2015 and 2019 were less likely to report receiving sex education on key topics than they were in 1995.
The same report found discrepancies in gender, such as that female adolescents between 2015 and 2019 were more likely than their female predecessors in 1995 to be instructed "on waiting until marriage to have sex." Sex education laws are determined on local levels, and as documented by Planned Parenthood, have been under attack since before overturning Roe v. Wade. Only 30 states and the District of Columbia require sex education to be taught in schools, and there's no guarantee for the information promoted to be medically accurate.
Engle added "pervasive patriarchal myths about condoms" could be to blame, too.
"There is this idea that cis-men will experience less sensation when wearing a condom, and therefore, don't want to use them," Engle told Salon via email. "This can lead to cis-men pressuring their female partners into forgoing condoms for the sake of their 'pleasure.'Tthis is a dangerous idea and can lead to unplanned pregnancy and the spread of STIs."
Ghareeb said alternative contraceptive options could be responsible for the decline in condom use as there are more effective birth control options such as intrauterine devices or oral contraceptives available.
"If you're taking the birth control pill or if you have the Mirena IUD, those are wonderful options that prevent pregnancy," Ghareeb said. "But those do not prevent the transmission of sexually transmitted infections."
For men who have sex with men, the rise of PreP could be to blame for a decline in condom use. Taking PrEP lowers a person's chances of getting HIV from sex by up to 99 percent. Users can take it one of three ways: as a daily pill, a bimonthly shot or "on demand" 2 to 24 hours before having sex. Most insurance plans cover PrEP — including Medicaid, according to Planned Parenthood. Public health research has concluded that the drug has decreased new HIV infections by a "statistically significant" margin. However, it doesn't prevent other STIs.
"The rise in the availability and use of PreP has led to a massive decline in condom use, as the fear of HIV transmission has diminished substantially," Engle said. "While PreP is an amazing drug and should be used by those who engage in sex with frequently with different partners, it does not prevent the spread of other STIs like chlamydia and gonorrhea."
From groceries to housing, the cost of living in the U.S. has increased over the last decade. Dr. Leandro Mena, the director of CDC's Division of STD Prevention, told Salon via email there are "social and economic conditions" that make it difficult for people to remain healthy, including protecting themselves from STIs.
"For example: poverty, stigma, and lack of medical insurance or a provider, unstable housing and a higher burden of STDs in some communities," Mena emphasized, also highlighting "decreases in condom use by some groups, including young people and gay and bisexual men."
Certainly, access to free condoms and cost are a barrier. In 2011, the average cost for a 12-pack was $10.99. Now, it can cost nearly $18.
"The prohibitive cost of condoms might be an issue for young people," Engle said. "This shows a need for more resources available to provide free condoms to high schoolers and college students."
A brief history of condoms
This isn't the first time condoms have taken a backseat in the public sphere. As examined by Planned Parenthood, condoms were discovered in the foundations of Dudley Castle in England, dating back to 1640. They were made out of animal guts, but still used as a barrier to prevent sexually transmitted infections. Historians remain unclear how accessible these condoms were to everyone. Condoms were also used in Ancient Rome and they were believed to be made out of linen or animal intestines.
It wasn't until the mid 1800s when condoms were mass-produced using rubber, soon becoming the most common form of birth control as manufacturing techniques improved. However, after the introduction of the combined oral contraceptive pill, condoms experienced a decline in sales, later making a comeback after the HIV and AIDS crisis.
"I think it's a really scary time for a lot of people in medicine, particularly in the reproductive health space,but also in infectious disease," Ghareeb said. "If you talk to any infectious disease specialist right now, one of the largest problems or STIs we're trying to combat is actually syphilis in heterosexual couples."
Ghareeb said this is concerning for a number of reasons.
"A lot of these STIs can have really grave consequences on fertility and pregnancy," Ghareeb said. "So when we're talking about things like chlamydia, gonorrhea, which often go asymptomatic, those can lead to scarring in the fallopian tubes and pelvic inflammatory disease that actually might predispose you to some issues with infertility later on."
Relatively "new" STIs like MGen are also on the rise, as well as sexually transmitted infections that are resistant to antibiotics. Ghareeb emphasized that there's been a 200% increase in congenital or neonatal syphilis in some parts of the country. Syphilis in pregnancy can lead to stillbirth, early pregnancy loss, skeletal deformities and sensorineural hearing loss. "And the distressing part is that it's preventable," Ghareeb said.
