I recently had to tell more than one woman that her baby may suffer permanent impairment or die from a sexually transmitted infection, or STI, that she did not know she had. Breaking bad news is not an uncommon experience in the life of an obstetrician/gynecologist, but in pregnancy it can be particularly difficult. Unfortunately, for many families the possibility of a new STI diagnosis affecting their unborn baby is becoming increasingly common.
In Texas, we have an abundance of opportunities to reduce the burden of STI transmission by improving access to education, health care and support for people who cannot advocate for themselves. And we have good reason to do it.
An alarming report by the Centers for Disease Control and Prevention released this month indicates that STI rates are on the rise, and cases of gonorrhea, chlamydia and syphilis reached an all-time high in 2018. This includes a 40% increase in rates of congenital syphilis. A pregnancy affected by syphilis can manifest as stillbirth, preterm birth or death.
In Texas, we have the highest rate of congenital syphilis, with 367 reported cases in 2018. Notably, transmission from an affected mother to her child is preventable in an appropriately treated patient. According to the CDC, “Women can protect themselves by practicing safer sex, being tested for syphilis by a health care provider, and if infected, seeking treatment immediately and asking her partner to get tested and treated to avoid reinfection.”
As a clinician who works in both a federally qualified health center and in private practice, I was really struck by this sentence. It seems like a simple suggestion for a complex issue. But it is not so simple.
Practicing safer sex seems easy enough but may not be the case in a variety of settings. For example, teaching abstinence-only sex education, as many Texas school districts do, prevents young people from learning appropriate information about what exactly constitutes safe sex and how infections may be transmitted. Many people are entirely unfamiliar with their own anatomy much less the many ways in which an STI can be acquired.
We need to invest in sex education that teaches young people accurate information about their bodies. This does not prevent people from practicing abstinence if they so choose. It also does not mean someone has to have sex before entering a partnership or marriage. The two are not mutually exclusive.
Being tested for syphilis and seeking treatment if infected is easier said than done in Texas. Many women do not qualify for health care until they become pregnant. And many men do not qualify at all. There is inadequate training for health care providers in culturally competent care that is free of implicit bias so that people feel comfortable seeking medical care. Funding cuts for STI clinics further exacerbate the unique challenges faced by our most underserved patients and creates barriers for the 4 million Americans who are considered to be in vulnerable communities.
And finally, getting your partner to get tested is problematic. This assumes that a person is in a healthy relationship. In addition to the poor insurance coverage of the underserved, including men, we are in an epidemic of sexual assault and intimate partner violence, both of which increase the risk of STI acquisition for a woman.
Importantly, a life event such as pregnancy can trigger more severe intimate partner violence including homicide, and there are numerous barriers to reporting these events. We need to improve training for screening and reporting for intimate partner violence. And we need to learn more about the right questions to ask, the best way to screen and to adopt universal screening, no matter the setting in which we work.
To quote our founding president: “Liberty, when it begins to take root, is a plant of rapid growth.” We have work to do in our great state in order to empower everyone, and especially our women, to safeguard themselves and their babies from the burden of these diseases.
If we want to implore people to protect themselves from STI transmission, we need to provide the tools necessary for them to do so.
Margaret Whitney is an assistant professor of women’s health at Dell Medical School at The University of Texas at Austin.
A version of this op-ed appeared in the Houston Chronicle.
