California’s Increase in Sexually Transmitted
Diseases: A Complex Problem
By Dr. Karen Smith, CDPH Director and State Public Health Officer
California is experiencing an unprecedented spike in sexually transmitted diseases (STDs). A record 300,000 cases of STDs were reported in 2017 – up 45 percent from just five years ago.
While it is easy to blame this on personal behaviors – and, yes, everyone should be using a condom, reducing the number of sexual partners, and getting tested – those of us who work in public health know these numbers tell a story that is far more complex. While there is no easy solution, we must speak openly about this challenge, and the steps needed to solve it.
Over the last decade, California has made significant strides in expanding health care coverage, especially under the Affordable Care Act. Most Californians now have the coverage they need to access primary care at health centers, clinics, and offices. But at the same time we were working to expand coverage, local health departments, faced with ongoing funding cuts, began shutting down what we hoped were redundant public health clinics – like those focused exclusively on STD screening and treatment. Today, despite the tremendous improvements in access to care for many health conditions, we must acknowledge and address that we haven't yet learned how to integrate traditional, "stand-alone" public health functions into the fabric of our health care delivery system. Many primary care providers do not routinely talk with patients about their sexual health, and many patients are uncomfortable raising this issue with their family doctor.
We also know that, while this is a statewide burden, the spike in STDs varies by geographic area and by population group. Just as we have to address how STD screening and treatment fits into the fabric of health care delivery, we must also address the tears in the fabric of our communities that are contributing to the STD increase, especially rising rates of mental illness, homelessness, and substance abuse, including opioid addiction. STD transmission tracks closely with this complex web of social issues. For those living on the edge, sex can be a means of survival. As long as increasing numbers of Californians are facing these issues, we will continue to see a corresponding rise in STD transmission. This is particularly true for congenital syphilis, which is closely associated with poverty and lack of access to health care. In 2017, there were 278 cases of congenital syphilis and 30 syphilis-associated stillbirths. This is unacceptable. It is only through addressing our social context that we can fully address the public health implications.
Finally, we know that STD transmission remains stubbornly high among young people. In 2017, 54 percent of chlamydia cases and 33 percent of gonorrhea cases were among people under the age of 25. Here, too, there are complex issues at play. Among youth, we have seen a change in social norms around condom use. Nationally, fewer and fewer young people are using condoms. And many are using "dating" apps that can make anonymous partners faster and easier to find. These changing norms and behaviors are also evident among gay and bisexual men, a population where STD rates are also increasing. We must ensure Californians are educated on sexual health, have easy access to condoms when they do choose to be sexually active, and have access to regular health screenings and treatment for themselves and their partners.
The factors behind the rising rates of STDs are complex, and every community and group is experiencing a somewhat different set of contributing issues. While there is not a proverbial silver bullet, California is not letting this alarming spike in STDs go unaddressed. In addition to increasing our disease control efforts, we have begun to raise awareness and start this crucial public dialogue. l am confident we will craft a uniquely California solution – one that brings together health care providers, public health professionals, and community leaders for the benefit of all. Together, we will tackle the root causes of this complex issue, and ensure Californians have access to the information, care and treatment we all deserve.