Reproductive Health

May the Best Sperm Swim: the Latest Research on Sperm May Surprise You

February 18, 2021 by Kristine Shields Leave a Comment

Screwy sperm

My house sits up on a bluff across the creek from a popular “put in” spot for kayakers. A picture with my house incidentally in the background once graced the cover of Kayaking Magazine! From my vantage point, I can watch the boaters as they navigate the rocks and the bridge pylons where the creek water rushes through. I was recently reminded of the kayakers while reading some new research on sperm movement through the female reproductive tract.

Turns out sperm don’t swim like we thought they did. If you’ve ever had the pleasure of seeing sperm under the microscope (so fun to watch! I used to occasionally spot them when I was evaluating vaginal fluid for STIs), or in videos, they appear to be whipping their tails from side to side like an eel as they swim along. But, not so. Turns out our little swimmers are more like one-armed kayakers paddling only on one side. You know what happens to them – they go around in circles. What keeps the sperm going forward? Like a kayaker doing a roll, the sperm moves in rotation. The sperm is actually rotating and stroking, actually drilling its way along the waterway towards the egg. I expect it’s the same movement the lucky winner uses to bore its way into the ovum once it gets there. (I encourage you to watch the sperm swim to the “Flight of the Bumblebee” here.)

Corkscrewing forward is not their only feat. Sperm are challenged when they reach narrow structures like fallopian tubes. The sperm are essentially swimming like spawning salmon upstream against the flow of fluid through the tubes. As the route narrows, the sperm are pushed back by the increased rate of flow. The weaker swimmers can’t fight against the tide, but the stronger (and smarter?) sperm swim to the walls where the flow is weaker and approach the pinch point from the side before making another attempt to sprint through the channel. Just like the kayakers do. The result is that only the strongest, healthiest sperm make it through the female obstacle course to the holy grail: the egg! But there’s even more to it than that.

We’ve known that the female reproductive tract is a sperm survival course where the swimmers are tested for their strength, geotracking ability, stamina, and their ‘major histocompatibility complex (MHC).” It’s more like an Iron Man competition than a swim meet. They must survive the acidic vaginal fluid, get through the molasses-like cervical mucus, fight off the antibodies that think they are foreign invaders (which they are), pick the right fallopian tube, and swim its entire 7-inch length (at the rate of about 1 inch every 15 minutes). Of the tens of millions of sperm in the ¾ teaspoon of semen that is released in a typical ejaculation, only about 250 reach the egg and only about ten percent of them are even capable of breaching the egg walls.

Now we find out that the egg is not just an innocent bystander in this whole process, like a princess at the end of a joust. Rather, she is actively reviewing the sperm CVs to decide which one she wants to recruit – another recent finding in human reproduction science. That sperm MCH I mentioned? It’s a bundle of genes that are programmed to fight infections. The egg wants to attract the sperm that has an MCH that contains genes that are different from the genes she herself has. That way, the offspring they create will be protected from a wider range of microbes and diseases. Ain’t she smart?!

So, Ms. egg has been secreting a secret sauce that attracts some sperm and repels others. The right Mr. sperm, who has an odor receptor on his head, is hopelessly attracted to her chemical perfume. He swims faster and straighter through the last two centimeters of follicular fluid to penetrate the egg and join his 23 chromosomes with hers. Tada! – we have a unique new embryo.

Other squirmy facts:

While researching this phenomenon, I gained some other interesting sperm expertise. First of all, I was unaware of the great interest in mammalian sperm. While looking for new discoveries in human sperm science, I was overwhelmed by the number of research papers dedicated to the sperm of animals including: mice, rabbits, hamsters, carp, bulls, stallions, boars, pigs, buffalo, Rhesus macaques, and zebrafish. Animal husbandry must be big business.

According to the World Health Organization, a normal human sperm count should:

have a concentration of at least 20 million sperm per ¼ tsp
be at least 1/2 tsp in volume
contain at least 40 million sperm in the ejaculate
contain at least 75% live sperm (it’s normal for up to 25 per cent to be dead); of these at least 30% should be of normal shape and form
be swimming with rapid forward movement (at least 25%)
be swimming forward, even if only sluggishly (at least 50%)

Healthy sperm are important to the survival of the species, right? You are likely aware that men today are making fewer (a decrease of over about 60% since the 1970s and still falling) and less virile sperm than they have in the past. This is occurring mainly in developed countries in North America and Europe and in Australia and New Zealand. Scientists’ best guess at the reason behind this continuing phenomenon is the “Western Lifestyle.”

What can be done to reverse this trend? Since we don’t now its exact cause, we don’t know its exact fix, but there are some well-researched recommendations. You can make your sperm more likely to win an Iron Man competition or survive a Class IV whitewater kayaking run by:

Eat less pizza, burgers, chips, processed meats (cold cuts), red meat, and sugary drinks

Eat more fruit, fish, walnuts, edamame and other beans, avocado, asparagus, lean beef, dark chocolate, garlic, and pomegranate. A vegetarian diet is also recommended.

Cut down or out: tobacco, alcohol, and weed

Get more sleep (at least 7 hours) and go to bed early (before 10:30 pm)

Wear boxers, not briefs – no more tighty whities

Supplement your diet with lycopene, vitamin C, and vitamin D

Exercise daily and keep your weight down

Decrease stress by utilizing relaxation techniques like meditation, yoga, breathing exercises, anger management programs, and counseling

My parting gift from sperm science: if you want sweet-tasting semen you should eat a diet rich in yellowish fruits like mango and pineapple. Furthermore, smoking (cigarettes or weed), alcohol, and coffee adversely affect its taste. So, there you go.

Addendum: Please check out Nicholas Kristof’s essay, “What Are Sperm Telling Us?” in the New York Times on 20Feb2021 – he talks about the endocrine disrupters that are disrupting our sperm – a really important issue that I missed in my blog. Worth a read!!

Women and Weed: Findings from Formerly Forbidden Research – Part 2. Pregnancy, Breastfeeding, and Insomnia

January 17, 2021 by Kristine Shields Leave a Comment

Pregnancy

The use of cannabis is most frequent in women between the ages of 20 and 30. This corresponds to the peak childbearing years. Since the potency of cannabis has increased and, with legalization, so has consumption of cannabis, there is increased cause for concern about the safety of using marijuana during pregnancy.

One of the great benefits of cannabis legalization is that researchers can now legally study the effects of the substance on animals and on humans. It is well known that the fetus is forming its major organs very early in pregnancy, often before a woman may suspect that she is pregnant. It is during this time that the fetus is particularly susceptible to anything that could impact its development.

Many people have the mistaken belief that marijuana, because it is a more “natural” substance than man-made medications, is naturally less likely to be harmful. A recent study indicated that about 11% of women in northern California used cannabis for nausea during pregnancy. Many women, lay healers, cannabis dispensaries, and even some health care providers may believe that since marijuana is effective for decreasing chemotherapy-induce nausea, it must also be good for relieving morning sickness during pregnancy. While it may have an effect (though no studies have determined this to be true), it may come at a cost to the developing infant.

We know that there are cannabinoid-1 (CB1) receptors in the placenta. We know that cannabinoids cross the placenta and enter the blood circulation of the fetus.

Findings from recent research on animals suggest that cannabinoids may inhibit fetal liver enzymes and decrease dopamine receptors in the developing fetal brain which might cause cognitive impairment.

It is difficult to evaluate the effects of substances used during pregnancy in humans, (for example, you couldn’t ethically design a study that gives cannabis at different doses to pregnant women to see how their babies turn out) so we must rely on animal data to inform ourselves of potential dangers.

Research studies in animals have found similarities between the effects of alcohol and the effects of cannabis on the growing fetus. Defects in the head, face, and brain found in fetuses exposed to alcohol are also being seen in fetuses exposed to cannabis. The damage appears to be higher with higher doses of cannabis. These defects can result in the emotional, cognitive, and behavioral issues common in children with Fetal Alcohol Syndrome (FAS).

Researchers have also found that cannabis can increase the negative effects of alcohol; together cannabis and alcohol are suspected to be even more disruptive to a developing fetus than either one alone. Both alcohol and synthetic cannabis (Spice, K2, Fake Weed, etc.) are known to cause birth defects; researchers are finding that plant-based THC and perhaps CBD may result in more subtle but similar effects.

Clinical studies in humans have not definitively determined that marijuana use during pregnancy causes damage to a developing baby. But animal studies suggest that it might. The animal studies are clear – there is a strong biological probability, and a clear mechanism of action for potential long term neurological impairment.

Because there are alternative medications and other treatments that we know are safe to use for many of the discomforts of pregnancy and concomitant illnesses, the best advice for pregnant women is to refrain from using recreational or medicinal or synthetic marijuana during pregnancy. As always, it is prudent to seek advice from specialists in obstetrics before taking any substance during pregnancy.

Breastfeeding

Yes, THC is found in human milk. There is a large variation from one woman to another in the amount of THC is found in their breastmilk; the average is a relatively low amount (at about 2%). Of course, this would vary based on the dosage consumed and each woman’s metabolism. The concentration is highest in the first hour and the active metabolites are usually gone after a few hours. THC may be detected up to 6 days after ingestion.

The American Academy of Pediatrics section on breastfeeding states that, “…cannabis can be detected in human milk, and [its] use by breastfeeding mothers is of concern, particularly with regard to the infant’s long-term neurobehavioral development, and thus [is] contraindicated.”

We need more and better data before we can say that recreational cannabis can be used without risk during breastfeeding. Breastmilk is known to provide important components for infants’ growth and immune system, so any amount of time spent breastfeeding is beneficial. Lactating women should at least space feedings away from times of cannabis ingestion or bottle feed at such times. Women who are heavy users may want to consider infant formula. As in pregnancy, more thoroughly tested medicines can likely replace medicinal cannabis for women who are using medical marijuana for physical illness, mental disorders, or pain.

Insomnia:

Insomnia is a very common health issue and its prevalence is increasing. Women identify insomnia as a problem more frequently than men. One study found the 63 percent of women and 54 percent of men reported struggling to attain restful sleep. Insomnia is one of the most common health-related conditions for which people seek to use medical marijuana and CBD.

Because THC and CBD are known to affect the regulation of anxiety, mood, autonomic function, and the circadian sleep cycle vis the endocannabinoid system, their application to sleep disorders is growing. Unfortunately, because of the legal issues, research in this area, like other areas, has been significantly delayed and is just now being undertaken in a systematic way. Most of the evidence we have to date comes from small studies, observational or survey research, or anecdotal data. Therefore, we can’t say with great confidence that cannabinoids are the solution to insomnia. However, there is promising preliminary evidence that they may be effective and that larger and more rigorously controlled studies are needed and should be done.

Preliminary research suggests that cannabidiol (CBD) may have therapeutic potential for the treatment of insomnia and that THC may be helpful in some circumstances but when used over a long period of time may impair sleep.

Insomnia is most commonly divided into three types:

Inability to fall asleep
Inability to stay asleep through the night
Inability to get back to sleep after waking early in the morning

Some people have no idea why they are experiencing sleep problems, but more often than not, sleep disturbance is due to other causes, rather than a primary condition.

Sleep disturbance is often caused by pain. Over 20% of adults report suffering from chronic pain. This number is expected to increase as the U.S. population ages. Some evidence that Sativex, a 1:1 THC/CBD compound and the synthetic cannabinoid, nabilone, may be effective in combating both pain and sleep disturbance.

Other common causes of sleep disorders include obstructive sleep apnea (OSA) which affects about 9% of American adults. Early studies indicate that synthetic THC (dronabinol) may be effective against OSA-related sleep disruption.

REM behavior disorder in Parkinson’s disease – loss of muscle rigidity during REM sleep, nightmares, and acting out behaviors linked to dreams. Found high-dose CBD may suppress the behavioral response to nightmares and improve sleep. More research is needed.

Similarly, nightmares often occur in people with post-traumatic stress disorder (PTSD). Preliminary findings indicate that THC and the synthetic THC nabilone reduced the occurrence and intensity of nightmares and increased time asleep.

Excessive daytime sleepiness (EDS) usually has an underlying cause such as medications, medical conditions, mental health issues, sleep disorders like narcolepsy, or OSA. Its severity ranges from mild to extreme and negative consequences may include behavioral changes, attention deficits, memory interference, frustration, increased anxiety and rumination, and immune impairment.

For some users, the THC itself can be an underlying factor in insomnia. While THC may initially help with falling asleep, long term chronic use may lead to habituation (the same dose has less effect than it used to) which may lead to the use of more frequent and higher doses which can increase the risk for developing cannabis use disorder (CUD).

As with many medications, CBD and THC concentrations, dose, route of administration and timing of administration may all affect success. Studies suggest that CBD at a low dose has a stimulating effect and is associated with increased wakefulness, while high dose CBD increases total sleep time and decreased frequency of arousal at night. For some, CBD may improve sleep quality because of its anxiolytic effect.

There is a potential therapeutic effect of high dose CBD and low-dose THC for sleep.

Other promising findings:

Synthetic cannabinoids like nabilone and dronabinol may have short-term benefit for sleep apnea
Nabilone may reduce nightmares associated with PTSD and may improve sleep among patients with chronic pain.
The synthetic cannabinoid HU211 is currently in clinical trials as a protective agent after brain trauma
Patients taking nabilone for neurogenic pain reported actually preferring cannabis because they found it relieved not only pain but also depression and anxiety associated with chronic pain

We obviously still have a long way to go before we can definitively recommend cannabis and its derivatives for specific indications. It is an exciting time for cannabis research as the field is growing and there are many discoveries yet to be made. Our understanding of the endocannabinoid system and our identification of the therapeutic applications of cannabis is just beginning.

Women and Weed: Findings from Formerly Forbidden Research, Part 1

December 20, 2020 by Kristine Shields 1 Comment

Part 1. Differences in Men and Women and Weed

Current legal status U.S.

First banned for use in the 1937 Marijuana Tax Act, cannabis remains under the regulation of the Drug Enforcement Agency (DEA) under Schedule I of the Controlled Substance Act of 1970 (with amendments through 2017). Drugs under Schedule I, by definition have a high potential for abuse and have no accepted medical use. However, some cannabis derivatives have been found to be therapeutic. Marinol (pure tetrahydrocannabidiol (THC) and dronabinol (synthetic THC) have been FDA approved to treat nausea and vomiting induced by chemotherapy and are listed in Schedule III. Pure cannabidiol (CBD; Epidiolex) is listed as a Schedule V substance and is used to control epilepsy caused by a rare pediatric seizure disorder. Other CBD extracts remain under Schedule I.

Because cannabis remained illegal in the U.S. until very recently, medical researcher’s ability to study the effects of THC on the body has been limited. Now that the plant has been legalized for medicinal and/or recreational use in many states, research into the effects, and potential therapeutic uses, of THC and other cannabinoids has escalated. One study published in the journal of the American Medical Association in 2014 found that states with medical marijuana laws had lower opiate overdose deaths by an average of 25%. On the other hand, recent findings of a fetal-alcohol-like birth defect has been reported in fetuses exposed to cannabinoids in-utero. Obviously, research needs to continue.

How does cannabis work in the body?

There are hundreds of chemical components, called cannabinoids, in the marijuana or cannabis plant. The one that is most obviously active, because it is psychoactive, is THC (delta-9-tetrahydrocannabinol), first identified in the cannabis plant in the 1960s. CBD is another. It wasn’t until the late 1980 and 1990s, while studying cannabinoids, that scientists discovered an entire signaling system, which they named the endocannabinoid (EC) system, that is responsible for mammalian biological homeostasis or balance.

Receptors in the endocannabinoid system respond to cannabinoid molecules that

1) are naturally made by the body (endogenous),

2) are ingested from a cannabis plant, or

3) are made in a lab (synthetic cannabinoids).

The human body has complex communication systems that send chemical messages from the brain to other areas of the body, and vice versa, along nerve pathways. The messages travel like trains back and forth from the central station in the brain along these pathways jumping from one nerve ending to another at specific junctions called synapses. The nerve junctions are spaces where chemical signals jump from the sending end of one nerve to the receiving end of the next nerve along a chain of pathways until the message reaches its intended destination station. Receptors on the receiving nerves have to fit perfectly with the chemical signal from the preceding nerves for the message to keep moving along the right pathways to get delivered to the right cells in the right places.

Smoking, vaping, or ingesting cannabis releases high amounts of cannabinoid chemicals into the system. By binding to the receptors in the nerves, the endogenous cannabinoids are blocked which interferes with the normal balance of the EC system. The overwhelmed chemical messaging system gets bogged down, the messages slow down, and a person feels “stoned.” It’s a train wreck!

Cannabinoid receptors are found in many areas of the brain. Therefore, THC would have an effect on many brain functions. For example:

This part of brain:	Regulates:	THC might cause:
Amygdala	fears and anxiety	paranoia
Hippocampus	learning	impaired memory
Nucleus accumbens	rewards	euphoria
Hypothalamus	eating	increased appetite
Spinal cord	conducting pain signals	altered sensation or pain
Neo cortex	complex thinking	altered judgment

The location of cannabinoid receptors is not limited to the brain; they are also found on nerves throughout the body. CBD is a cannabinoid created endogenously or ingested. While similar in structure to THC, CBD is not psychotropic or intoxicating and is only minimally active in the brain. THC binds most specifically with CB1 receptors in the brain and CBD binds more specifically with CB2 receptors throughout the body – particularly with the CB2 receptors in the immune and gastrointestinal system. That helps explain THC’s predominantly psychotropic effects and CBD’s major benefits in chronic pain syndrome relief and inflammatory bowel syndromes. The density and balance of cannabinoid receptors vary from person-to-person, which is why one person will get a happy high and another will be predominately paranoid after smoking the same amount of weed.

Differences in cannabis use and response between women and men

Cannabis use in women has greatly increased over the past five to ten years. In women between the ages of 18 to 25, the overall use of weed increase by 20%, daily use rose 13%, and the reported incidence of cannabis use disorder (CUB) increased by 30%. In women over the age of 26, both monthly use and daily use increased by 40%.

While a higher percentage of women report using weed for medical purposes, more men are registered for medicinal use across the U.S.

Women and weed:

Lower numbers of women use weed and they tend to start using it later in life

More likely to prefer oral ingestion over other forms of intake

Different responses at different times and with different cannabis strains, likely due to levels of estrogen (more sensitive to THC with high estrogen levels (e.g, at ovulation) less sensitive to THC effects when have low estrogen levels (e.g., at menses)

Higher rates of use for medicinal reasons like pain and anxiety, and to help cope with social and psychological stress; dysmenorrhea, PMS, nausea, bloating, headaches

Higher number and density of CBD receptors in brain and body; probably why women need a lower dose of THC to get same degree of intoxication

More likely than men to get anxiety-related symptoms from occasional use

CBD causes a markedly steeper decrease in anxiety in women than in men; THC at low doses relieved anxiety and at high doses increased anxiety, CBD showed no difference by dose.

THC more effective than CBD in relieving centralized pain in women

THC more effective for improving quality of life, anxiety, and depression in women than in men

Higher side effects of THC – anxiety, paranoia, dizziness, disorientation (difficulty navigating especially through unfamiliar areas, locating items, feeling off-balance), especially at higher doses

Increase in hunger about 3 hours after ingestion*

At smaller doses, increases sexual appetite in women (high doses decrease this effect)

Chronic use may negatively affect women’s memory and emotional processing centers.

Less likely to develop CUD, but shorter time progression to CUD; have more difficulty stopping use and relapse is more likely; in CUD, have more anxiety disorders and panic attacks.

Men and Weed:

Higher rates of use by men (3/4 of all users are men); men start at an earlier age than women and have more access to drugs in general

More likely to smoke or vape over edibles

More stable reaction to THC (consistent reaction to specific strains)

Male hormones are affected – THC blocks production of gonadotropins in the pituitary gland and elsewhere, depressing the production of testosterone and other hormones, and interfering with prostate function and sperm production

Higher rates of use for recreational purposes (about 62% of recreational users were male)

More likely to be using other substances as well

THC and CBD do little to decrease in anxiety in men and CBD may increase anxiety

THC more effective at relieving peripheral pain in men than in women

Experience increased appetite immediately upon smoking THC*

Causes decreased sexual appetite and sperm production

Results in higher rates of cannabis use disorder (CUD) and more severe symptoms

Take longer to build up tolerance to weed and develop CUD than women

*Animal testing found that THC increased the consumption of sweetened condensed milk by male rats in the first through third hour after injection, but didn’t increase consumption by female rats until the third hour after injection. Similar responses were seen in guinea pigs.

Studies show that cannabis affects men and women differently, for several reasons. One is that men and women start out differently. Women are more likely to struggle with pain, sleep deprivation, anxiety, and depression. Because of all those cannabinoid receptors in the brain, THC affects issues that start in the “head” like anxiety and pain:

Anxiety: THC and CBD both reduced anxiety levels in studies of men and women. But women showed a steeper decrease in anxiety than did men after smoking weed. Women started out with higher anxiety levels and ended up with lower anxiety levels than men. But there is a cautionary note. Low doses of THC worked better to reduce anxiety than higher doses. At higher doses, anxiety increased.

CBD, on the other hand, also decreased anxiety in women and had no dose effect; no danger of taking too much and worsening the anxiety. Men, however, saw no decrease in their anxiety with the use of CBD – in fact, they experienced higher levels of anxiety. These findings are similar to the results of CBD testing in anxious mice as well. In a paradoxical twist, CBD can reduce anxiety induced by THC, though no human studies have been done to test this.

Pain: Interestingly, pain is perceived and experienced differently by men and women whether we are talking about acute pain or chronic pain. Women have much higher sensitivity to external stimuli in the environment and more internal pain throughout the body. Some scientists think it is due to estrogen, some think there may be more pain receptors in their brains. Because of this increased sensitivity, women have higher rates of chronic pain conditions.

Recent studies suggest that men and women respond differently to types of pain. Men are more sensitive to inflammatory pain, like arthritis, or knee injury, or tooth ache. Women are more sensitive to nerve pain and centralized pain, like sciatica, migraines, stomach pain. Successfully treating different types of pain may depend on whether the patient is biologically male or female. For example, women get more pain relief from opioids than men do but they also experience more side effects. Therefore, women might feel better on a lower dose. Studies on cannabinoids have found that CBD is more effective at relieving peripheral and inflammatory pain (the kind of pain that men are more sensitive to) and THC works better against nerve and centralized pain (the kind that more women suffer from).

Women experience about twice as much chronic pain as men and experience more pain during the pre-menstrual phase of the menstrual cycle when their estrogen levels are high. Because pain cues come from the brain, and women have more cannabinoid receptors in the brain, tricyclic and SNRI antidepressants and cannabinoids can be effective at treating their pain.

If seeking pain relief, trying CBD first is the safer option as it is lower in unwanted side effects than THC. However, adding a low dose of THC (low dose THC works better for pain than high doses) may help if pain is not relieved by CBD alone.

Map Source: https://disa.com/map-of-marijuana-legality-by-state

Coming up soon:
Women and Weed: Findings from Formerly Forbidden Research
Part 2 – Pregnancy, Breastfeeding, and Insomnia

We’re Actually in the Middle of two Pandemics

October 7, 2020 by Kristine Shields Leave a Comment

Do you have coronavirus fatigue?

Are you tired of talking about the coronavirus pandemic? Yeah?

Let’s talk about the other pandemic instead. What other pandemic, you say?

The STI pandemic.

What STI pandemic, you say?

The STI pandemic that no one’s talking about.

What’s going on with STIs?

Over 100 million Americans have an STD at any given time. That’s about one in every three of us. America has the highest rate of curable STDs among all the developed countries in the world.

So, is this just an American thing?

No. Rates of syphilis increased by 70% in the EU between 2010 and 2017. In fact, 2017 was the first year since the early 2000s that more syphilis cases than HIV cases were reported. Syphilis rates increased by 876% in Iceland, 224% in Ireland, 153% in the UK, and 144% in Germany. See ~figure:

World Health Organization data indicate that chlamydia and gonorrhea rates are highest in the Americas and Western Pacific countries, syphilis is highest in African countries, and trichomoniasis is highest in the Americas and African regions.

How bad is it?

Look at some of these U.S. numbers:

Chlamydia cases have increased by 19% since 2014.
Gonorrhea had its lowest numbers ever in 2009 – since then the numbers have increased by 83%.
Syphilis, for which the numbers were falling fast in the 1990s, has increased by 173% among women of childbearing age. And there has been a 185% increase in the number of babies who get congenital syphilis, many of whom do not survive.

It’s really pretty serious, right? The outcomes of untreated STIs, many of which are asymptomatic, are dire: infant death, infertility, chronic pelvic pain, cancer.

Who’s getting these STIs?

Men who have sex with men have the highest rates of STIs followed by heterosexual men, heterosexual women, and lastly, women who have sex with women.

What age range do you think has the highest rate of STIs? Teens, young adults, middle age adults, or over 65s?

Young adults? Nope. Teens. Adolescents only make up about one-third of the population but they have about one quarter of the STIs. They are undereducated and unprepared.

In what age group do you think the rate of STIs are going up the fastest?

Teens? Nope. Over 65s? That’s right! The rate of STIs is increasing the fastest in those people greater than 65 years old.

But there is no age group that is not being affected by the rise in STIs. Nor is any state immune. In 2018, the rate of chlamydia was highest in Alaska, the rate of gonorrhea was highest in Mississippi, the rate of syphilis was highest in Nevada, and the rate of congenital syphilis was highest in Texas. STDs are everywhere.

U.S. Cities with the Highest STI Rates^
Rank	City	Cases per 100K people	HIV	Gonorrhea	Chlamydia	Syphilis
1	Baltimore, MD	2,004	207	4,231	7,636	210
2	Jackson, MI	1,872	86	1,330	3,057	52
3	Philadelphia, PA	1,822	499	7,288	21,119	459
4	San Francisco, CA	1,754	246	5,775	9,137	584
5	Montgomery, AL	1,731	71	1,045	2,828	36

Why now?

Why we are having an STI epidemic right now? Weren’t the rates going down?

Yes, the numbers were decreasing in the 1990s but the rates now are moving up fast. There are a number of factors that are involved in increasing the rates of STIs:

HIV

It’s incredible how far we’ve come in understanding and treating HIV. (No reason to think we can’t do the same with coronavirus). The current medication regimen for people living with HIV can be so effective in bringing down the viral load, that it is undetectable in HIV tests. And if HIV levels are so low that they’re undetectable, then they are not infectious! They can’t infect someone else! U=U – undetectable equals untransmissible.

Everyone is relieved that the risks of acquiring or dying from HIV have greatly decreased since the end of the century, but with all of the focus on HIV, less attention and less money was being given to programs to prevent and treat the other STIs.

PEP and PrEP

There are now effective medicines that prevent people at risk for acquiring HIV from getting infected. Pre-exposure prophylaxis (PrEP) which is taken before sexual activity and post-exposure prophylaxis (PREP) that is taken after sexual activity are highly effective in preventing HIV infection. But PEP and PrEP do not prevent other STIs.

Since it has become less likely that one might contract HIV and less likely that, if you did get it, you would die from it, some people have become lax about maintaining safe sex practices.

Condom fatigue

After the HIV/AIDS crisis in the 1980s and 1990s, condom use went up a lot and the rates of STIs (and pregnancy) went down. Now though, it seems that “condom fatigue” has set in and people may be not as strict about using condoms consistently as they were before AIDS became a chronic disease instead of a killer disease.

The opioid crisis

People who exchange sex for drugs, are less likely to use condoms and more likely to have multiple sex partners which puts them at higher risk for acquiring STIs. Some drugs increase sexual desire and decrease sexual inhibition. People addicted to drugs exist in all socioeconomic groups and don’t necessarily limit sexual activity to within their drug-using circles.

Other factors

years of decreased STI program funding decreases clinic hours and access to STI screening and treatment, increasing STI rates and STI damage
lack of health care insurance negatively impacts being able to afford STI services
clinic closings because of local and national government withdrawal of support for reproductive health services
dating apps that increase anonymous sex, the “hookup app effect”

How is COVID-19 affecting the STI situation?

We don’t really know yet. On one hand, with social distancing we expect fewer new sex partners, casual sex partners, and multiple sex partners. The use of telehealth has increased, as has at-home testing kit availability for STIs. On the other hand, 66% of sexual health clinics have had to cut back service hours, 85% of staff have been redirected from STI contact tracing to COVID contact tracing, fewer patients are going to clinics to be tested, and there have been interruptions in access to prescription medicines for HIV treatment and prevention (pre-exposure prophylaxis [PEP] and post-exposure prophylaxis [PrEP]), along with birth control methods that require in-person visits. We have to wait and see what the overall impact of COVID-19 on STI and pregnancy rates will be.

Why isn’t more being done to address the STI epidemic?

As the COVID-19 epidemic is demonstrating, governments find it easy to ignore public health issues until they are in crisis proportions. One big reason that the STI epidemic is growing is that our current political climate is not conducive to helping people, especially underprivileged people, to get the health care coverage, screening, and treatment that they need.

STI stigma, the negative attitudes that society projects onto people who have an STI, includes the judgement that the people who get them deserve them. Stigma makes people fearful to admit they’ve had or might have one, or to talk to health care providers about them, or to seek screening and treatment. So, while stigma is meant to create a negative environment so that people will act to decrease risky behavior and improve society, in fact, stigma prevents people from adopting behaviors that can decrease their personal and their community’s risk.

Our grandparents’ generation didn’t talk about a neighbor’s diagnosis of TB, polio, or cancer outside of the family. These diseases were stigmatized. We are better about that now. Even mental illness is slowly coming out of the closet. So, things can change if we can decrease STI stigma.

What can we do?

Yes, we can lobby for more funding for STI programs, urge our representatives to depoliticize reproductive health care, promote comprehensive sex education in our schools, and donate to sex-positive organizations.

But my message to you is much simpler and more fun: talk about STIs like they were the flu or poison ivy. I can tell you that raising the subject of STIs among your friends can lead to some hilarious conversations. Lift the stigma!

Use condoms, get tested, get treated. Be careful out there!

*Image: Pretty vectors Designphotos.com

~Figure. https://onlinedoctor.superdrug.com/std-us-eu/

^Table. https://www.innerbody.com/std-testing/std-statistics

STD, STI, or maybe STID? Stumbling over terms hinders communication

September 15, 2020 by Kristine Shields Leave a Comment

STD: sexually transmitted disease — a term used since the mid-1970s for an infectious disease that is usually transmitted during oral sex, anal sex or other intimate contacts with the genitals. It is generally thought that the change from venereal disease (VD) to STD was intended to decrease the stigma associated with the antiquated term VD.

STI: sexually transmitted infection — a term introduced in the 1990s for a sexually transmitted infection that is asymptomatic (has no symptoms) and that may or may not develop into a disease with observable symptoms. This term was considered to be more accurate because some infections never turn into a disease whether they are treated or not. The term ‘infection’ was also thought to be less stigmatizing than the term ‘disease.’

An infection arises when an organism that has the potential to cause disease invades the body. An infection is declared a disease only when it causes damage to the body that is characteristic of the specific organism. Someone could be infected with a microbe, say polio or tuberculosis, and never have any symptoms. They are infected but are not diseased. Others infected by the same microbe can have all the symptoms of, and die from, the same infection — they have the disease.

This is where it gets confusing. Some STIs remain STIs, some STIs can turn into STDs, and sometimes it’s hard to know which is which.

Due to this confusion, a new term was proposed by a linguist and medical editor, Janet Byron Anderson, in the 2016 article entitled, “STD (sexually transmitted disease) or STI (sexually transmitted infection): Should we choose?”[i] Dr. Anderson makes several arguments in support of new terminology, some of which I’ve summarized here, with additional commentary:

1. The terms STD and STI are being used interchangeably, the difference between them is minor and confusing, and people, outside as well as inside the medical professions, don’t know which one is “right.”

2. If an STI remains asymptomatic by definition, does it change to an STD when the symptoms show up? Would HIV be the STI and AIDS be the STD? Do you have an STI if your herpes blood test is positive but an STD after an initial outbreak? Technically, the terms should not be used interchangeably, but the difference between them is not well delineated and is, therefore, confusing.

3. When we speak about STDs or STIs in general, should we always say “STDs and STIs” or write STD/I in order to be accurate and inclusive? That’s a mouthful, to use an indelicate term in this situation, and does away with the benefits of using acronyms in the first place. Saying “STD slash I” is ridiculous and reading STI/D can be annoying, as illustrated in this paragraph.

4. Another issue raised by Dr. Anderson is that the words ‘transmitted’ and ‘transmissible’ are significantly different. Transmitted suggests a past event, while transmissible describes a potential event. To call an STD/I ‘transmitted’ is to have diagnosed it in a person; to call an STD/I ‘transmissible’ is to identify it as an agent to protect oneself from. These two scenarios require different approaches: the former patient needs a treatment plan, the latter needs a condom. Words are important in medicine.

5. The Zika virus disease is primarily a vector- (mosquito) borne infectious disease. It can also be transmitted sexually. It is a sexually transmissible infectious disease, a STID. Many STI/Ds can have non-sexual transmission via clothing (crabs), intravenous drug use (HIV, hepatitis B), tattooing (hepatitis B), blood transfusions (HIV, HBV), birth (syphilis, gonorrhea, etc.), or dear old Aunt Ethel’s kisses (herpes-1) to name a few.

6. Ms. Anderson states, the term STID “captures more comprehensively the pathogenesis of the sexual illnesses, from the initial presence of the infective agent to the potential transfer of the agent to a susceptible human host, culminating in [an infectious process and] a possible disease.” I agree with the linguist’s carefully parsed conclusion.

7. She also concedes that “the monosyllabic STID is easy to read and say,” while allowing that “its full name is a bit of a mouthful, even for a linguist!” However, medical terminology is full of acronyms that simplify complex terms to facilitate communication as in BP, EKG, MRI, TB, DNR (do not resuscitate), NKDA (no known drug allergies), ADHD, etc.

I’m not sure that society is ready to adopt a new term when we are still struggling with the old ones but I do know that there is confusion about whether or when to say STD or STI and which one is more correct.

We are currently in the middle of a pandemic — an STI/D epidemic. As we learned from COVID-19, the best way to fight a pandemic is to widely spread accurate information about the infectious nature of the pathogen and the steps that need to be taken to protect ourselves and each other from contracting it. In the case of STIs and STDs, people hesitate when they speak, deciding in their heads which term to use, which one is right. Stumbling over terminology makes communication more difficult. This most basic distraction does not help us deal with an epidemic.

If I had to name them today, I’d call them STIDs.

[i] Anderson, JB. STD (sexually transmitted disease) or STI (sexually transmitted infection): Should we choose?” American Sexual Health Association. 2016. Available by clicking here.

Excerpt from my upcoming book, My Life in STDs.

Conservative Policies Increase American Babies’ Risk

July 13, 2020 by Kristine Shields

Please don’t miss the frightening message from a reader at the end of this page.

The Zika crisis has exposed the consequences of religious opposition to affordable and accessible birth control methods in Latin America. Over 4000 babies with Zika-related birth defects have been born in Brazil alone. Unless the US wants a modern-day version of the thalidomide tragedy, we should learn from our Latin American neighbors.

Babies with Zika-related birth defects have already been born in New York, Florida, Texas, and California. Those are just the tip of the iceberg. As of October 12, 2016 there are close to 4,000 cases of Zika infection in the US including 878 pregnant women and over 25,000 cases in US territories that include almost 2000 pregnant women. The World Health Organization (WHO) has declared a global health emergency.

For the babies who contract the Zika infection during the first trimester of pregnancy, it is estimated that between one and thirteen of every hundred will have microcephaly and/or other defects associated with Zika infection including: mental retardation, impaired coordination, blindness, inability to eat or speak, dwarfism, seizures, hyperactivity, and other brain and nervous system abnormalities.

Many Zika-affected babies survive after birth and require lifelong intensive care and therapy.

In areas with active Zika transmission, public health experts are advising women of childbearing potential to consider avoiding or delaying pregnancy. WHO recommends that the full range of contraceptive methods, including emergency contraception, along with accurate counselling to enable informed decision-making, be readily available to sexually active women and men.

Unrestricted access to effective contraceptive methods is necessary to help women and families avoid unplanned pregnancies.

But even as the Zika outbreak was reaching our shores, between July 2015 and July 2016 twenty-four states made efforts to impede women’s access to contraceptive methods by limiting funding for family planning services. These restrictions disproportionately affect poor and adolescent women – the same women for whom raising a child with severe disabilities is most burdensome.

https://www.guttmacher.org/article/2016/07/laws-affecting-reproductive-health-and-rights-state-trends-midyear-2016

Ironically, many of the states that have proposed these restraints are in regions of the country where women are most at risk for unintended pregnancy and most at risk for contracting the Zika virus (the Southwest and Southeast).

https://www.guttmacher.org/newsrelease/2016/countering-zika-womens-right-self-determination-must-be-central

In addition to restraints on family planning services, during the same period thirty-two states attempted to ban all or some abortions, and fourteen (most in southern states) implemented abortion restrictions. Again, these states are among those with the highest risk for unplanned pregnancy and for infection with the Zika virus. These states will also bear a burden of care for children with Zika-induced birth defects.

Ideological and religious opposition to contraception and abortion are responsible for regressive policies and programs that adversely affect women’s health. Whether women are of the same ideology or religion does not seem to matter.

Half of US pregnancies are unintended (not necessarily unwanted, but not planned). With the Zika crisis now in the US states and territories, mosquito eradication, personal protection from mosquito bites, ensuring the safety of the blood supply, and population surveillance are planned. Access to effective means of birth control and emergency contraception in the event of birth control method failure to prevent unintended pregnancies are also needed.

In addition, we need support for expectant mothers and fathers who, in consultation with their health care provider and spiritual advisor if they so wish, will need to make the difficult decision of whether or not to abort a fetus that has been diagnosed with birth defects. The people who will be responsible for the lifelong care of the affected child should be the ones to make that decision, not members of a political party or church, or a legislator who likely has not been, nor ever will be, in that intricate situation.

The Zika crisis is about to expose the consequences of political opposition to affordable and accessible women’s health care services and social policies that support families. It may also reveal the vulnerability of US families to the most personal and potentially tragic after-effects of political interference in reproductive freedom.

This commentary first appeared in an edited version on the Ms. Magazine blog, 31October2016. About 4 months later it received one comment. It is even more frightening than the blog. Please read it.