Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
I met my patient, a 28-year-old cisgender male, while I was an attending on the Infectious Diseases consult service at an academic hospital. He told me that he had no significant medical history until about a week prior when he started having subtle changes in his vision. When he was admitted to the hospital, he was having sudden left-sided weakness that made him collapse at work. After I examined him, I found symptoms consistent with uveitis, an inflammation of the eye, as well as signs consistent with a stroke. His physical exam revealed a rash on his trunk that he said he had for about a month. His sexual history included sex with both men and women, and he reported three male sex partners in the last month. He reported no drug use and consumed alcohol primarily on the weekends, never exceeding four drinks at one time.
I asked myself: What could possibly cause a stroke in an otherwise healthy 28-year-old? I ordered the standard battery of tests for a stroke, all of which were negative. An astute intern, who wondered about the rash, sent a rapid blood test for syphilis. Mystery solved — he had neurosyphilis and ocular syphilis. Without treatment, those conditions can lead to blindness and to dementia, permanent paralysis, and even death.
In January 2024, the Centers for Disease Control and Prevention (CDC) issued its annual report on sexually transmitted infections (STIs), which included an unprecedented rise in cases of syphilis. In 2022, the most recent year for which statistics are available, more than 200,700 cases of syphilis were reported in the United States, an 80% increase since 2018.
Most people think of syphilis as an antiquated disease, something relegated to the history books. In fact, the United States is currently in the midst of a syphilis epidemic that continues to climb every year.
This epidemic includes not just adults but children too. In 2022, more than 3,700 babies were born with congenital syphilis, more than 10 times the number of cases reported in 2012. Tragically, congenital syphilis often leads to stillbirth or death. Over the past decade, 1 in 13 congenital syphilis cases has resulted in such losses. And yet 9 in 10 of those cases might have been prevented by timely syphilis testing and treatment during pregnancy.
Indeed, timely testing and treatment are critical, as untreated syphilis can have a devastating impact. Untreated syphilis can progress through four stages, each with different signs and symptoms, some harder to identify than others without testing.
In adults, untreated syphilis can lead to irreversible brain damage, cardiovascular disease, vision and hearing problems, and death. Congenital syphilis occurs when syphilis infection passes to a baby during pregnancy. In babies that survive, congenital syphilis can have long-term effects on their hearing, vision, and brain development.
Although the impact of syphilis is widespread in the United States, we also know that certain groups of people are more affected by STIs. Data show that some racial and ethnic minority groups, gay and bisexual men, and our nation’s youth continue to experience higher rates of STIs. Why? Longstanding factors — such as lack of access to regular medical care, discrimination, and stigma — continue to stand in the way of quality sexual health care for everyone.
As a physician, I’ve treated a range of patients for syphilis, from the sexually active male college athlete to the married pregnant woman who has had only one lifetime sexual partner. No matter a person’s background, race and ethnicity, sexual orientation, or age, today’s syphilis epidemic touches nearly every community.
Health care providers have two main tools — testing and treatment — to identify and treat syphilis and to prevent congenital syphilis. What are we missing? What more can we do — as individuals, as a community, as a nation — to reduce the spread of syphilis?
1. Normalize discussions about sexual health.
Providers need to talk about sexual health during clinic visits so we can destigmatize the topic. Sexual health care is health care. Sexual health can greatly impact a person’s overall quality of life. The health effects of STIs, one component of sexual health, can range from irritating to life-threatening.
Yet, discussing sex and STIs makes some of us uncomfortable. That stigma means we don’t talk about sex as it relates to health as frequently. It’s hard to have a conversation with your doctor about STI testing, available STI vaccines, and ways you can reduce your risk of getting an STI if neither patient nor provider takes the first step to start the conversation.
“I only have sex with women.” This was the answer a male patient of mine, who had acquired HIV in his late teens, routinely gave me at his check-ups. I’d been seeing him for a couple of years, and at his check-ups, we’d talk about his sexual health and the gender of his sex partners. He maintained that he only had female partners. Over time, he came in with a variety of STIs, including syphilis and shigella, another bacterial STI. Based on his STI history, his current sexual history, and any symptoms he may have mentioned, I’d order the necessary STI tests. Understanding the patient’s experiences in conjunction with who should get tested for STIs is key. Usually, one STI test would come back positive. Our dialogue during his visits expanded over time. We talked about his family life, the challenges he had with his mother, his future career aspirations, and his interests. We had rapport. There was a level of trust — but that trust did not include his sexual health for the first two years that he was my patient. Then, during one appointment, he confided in me, “I have only had sex with men — ever. I have never had a female sex partner.”
Self-stigmatization can lead to people not readily disclosing important aspects of their sexual history.
Just like people in a relationship build trust with each other, providers and patients must do the same. Even when providers think we know how to take a culturally sensitive, non-judgmental sexual history, patients can have difficulty disclosing their sexual behaviors. It’s not our place as providers to judge or rush the patient’s disclosure process. Relationship-building takes time.
In order to have productive conversations about sexual health with patients, providers can take a number of steps. Those include gauging their own comfort discussing sex with various types of patients and identifying any biases they have. They can also work to make their patients feel comfortable by building rapport before asking sensitive questions. They also should avoid making assumptions about their patients and instead use open-ended questions to better understand the health care needs of each patient.
2. Increase access to testing and treatment.
We need to be innovative in how we try to reach people who would benefit from STI testing and treatment.
In 2022, 38% of congenital syphilis cases occurred in pregnant persons with no access to traditional prenatal care. However, they may have been in other places that could have tested and treated for syphilis, including emergency departments, jail intake settings, syringe service programs, and maternal and child health programs.
At one medical school where I taught, a student group went into the community to talk to people about STIs and offer screening, meeting people in college campuses, nightclubs and bars, and other venues. Not only did this provide the community with other avenues to access care outside of a traditional clinic setting, but it also gave these soon-to-be doctors an opportunity to understand how complex stigma can be and practice strategies to break it.
Not everyone will access health care for a variety of reasons, so it’s critical to think of other ways to reach people, and that requires a robust public health infrastructure. From disease intervention specialists who use contact tracing and case investigation to prevent and control infectious diseases to community health workers who engage in activities from advocacy to community education and informal counseling, these are vital public health professionals. Through their work, they ensure that individuals can access sexual health care that works for them.
3. Advance syphilis testing and treatment.
Advancement in syphilis testing and treatment is long overdue.
Many people don’t realize that the most common syphilis testing and treatment options are decades old and limited in number. The original syphilis tests were developed more than 100 years ago and relied on directly viewing the syphilis-causing T. pallidum bacterium with a microscope or on detecting antibodies to syphilis in patients’ blood. While the blood-based tests were groundbreaking for their time, these tests suffer from the same problems that plague their modern counterparts: they cannot tell if someone has a current or active syphilis infection or if the test results are picking up a prior, treated infection. This makes testing and interpreting results for syphilis confusing.
Adding to these challenges is the fact that there is only one first-line recommended treatment for syphilis— long-acting benzathine penicillin G. The penicillin preparation, dose, length of treatment, and the route of administration — a shot or through an IV — is dependent on the stage and symptoms of syphilis. Having one first-line drug option coupled with the limitations in testing and challenges in interpreting results creates a complicated recipe for diagnosing and treating syphilis.
We desperately need new drugs to treat and prevent syphilis, as well as new tests to identify active syphilis infection in a variety of clinical and field settings.
Repurposing the antibiotic doxycycline as a preventive measure after possible exposure — post-exposure prophylaxis, known as “doxy PEP” — holds promise. Doxy PEP can help stop the spread not only of syphilis, but other bacterial STIs. However, research has established its efficacy only among some gay, bisexual, and other men who have sex with men, and transgender women. While we await additional research on efficacy in other populations, some providers still may choose to discuss doxy PEP using a shared decision-making approach.
4. Prioritize STIs for public health outreach.
STIs must be a public health priority with everyone playing a role in their prevention.
The CDC and publicly funded STI programs cannot do this work alone. Universities and private industry, health care providers and health departments, communities and community leaders, federal, state, and local governments all also must play a role. While the work and decisions made at the federal level have a large impact (in terms of guidance, direction, and partnering to provide expertise), combating the syphilis epidemic will require increased ownership of the problem.
It is imperative, now more than ever, to execute the first-ever, whole-of-nation STI National Strategic Plan. And with the recently established National Syphilis and Congenital Syphilis Syndemic Federal Task Force pulling together resources and collaborating with key stakeholders, we have a good chance at slowing the epidemic.
5. Create safe spaces for patients.
Providers need to know that it's okay to not understand all the nuances of sexual health.
When I think back on medical school, I remember we spent a tiny fraction of our time learning about sexual health outside of pregnancy. In practice, I have found my patients to be the best teachers on the subject. If health care providers are open with patients and create a trusting environment, the patients are often happy to tell us what is going on with them.
We have the basic tools to prevent and treat syphilis, including congenital syphilis. By creating a welcoming and safe environment for patients in clinical settings, educating the public about sexual health, and engaging the whole of society in STI prevention and control, it is possible to curb the epidemic.
The alarm on syphilis has been blaring for years. It’s time we wake up and act before it’s too late.
