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Sex positivity is in, sex shaming is out. More people are comfortable talking about what it means to have a healthy sexual relationship, and that’s a good thing.
But there’s one thing that many of us still feel awkward or downright avoid talking about: sexually transmitted infections (STIs).
You may know them as sexually transmitted diseases, or STDs, which is the term doctors use when an STI has symptoms. (We’ll be using the term STI throughout this article because it’s broader.)
This omission can lead some people to assume there’s no real risk, says Dr. Lindley Barbee, an infectious disease specialist and medical director for the Public Health Seattle & King County STD Clinic at Harborview Medical Center.
Unfortunately, the risk is very real. Consider this the STI 101 class you probably never got in high school.
STI rates are going way up
Two of the most common STIs in the country, chlamydia and gonorrhea, are getting more common. From 2014 to 2018, rates of chlamydia rose by 19% while rates of gonorrhea rose by a whopping 63%, according to a national report from the Centers for Disease Control and Prevention (CDC).
In Washington state, there were 465 cases of chlamydia per 100,000 people and 151 cases of gonorrhea per 100,000 people in 2018. These rates are midrange, neither the highest nor the lowest in the country.
And so much for that idea that millennials aren’t having sex: STI rates are increasing the most among teen and millennial women.
Doctors don’t know why STI rates are so high, but it’s likely due to several factors, Barbee says, not all of which are bad.
Thanks to medical advances like a variety of birth control options and the development of medications to prevent HIV, it’s easier than ever to have sex without the risk of pregnancy or HIV infection.
This is a big cultural shift from just a few decades ago, Barbee says, which means people may not be using condoms as often now because they feel safer.
Yay for being able to get it on with fewer life-altering risks. Nay for assuming that means there aren’t any other risks.
STIs often have no symptoms
You may think all STIs cause symptoms — things like a burning feeling while you pee, smelly discharge or pain in the affected area — but that’s simply not true.
Though anyone can get infected without having symptoms, people with vaginas are particularly at risk.
“With gonorrhea and chlamydia, 50% or more of vaginal infections aren’t going to have symptoms,” Barbee says.
This is a problem for two major reasons.
First, if someone doesn’t know they have an STI, they probably won’t get tested and treated, and untreated STIs can cause serious health problems (more on that shortly).
Second, if someone doesn’t know they’re infected, they’re likely to pass on the infection to their next sex partner if they aren’t using protection during sex.
This is especially true for chlamydia. No wonder it’s the most common STI in the United States: Research suggests that only 10% of men and up to 30% of women who get chlamydia will develop symptoms. Plus, the infection can be in someone’s body for weeks before they do get any symptoms from it.
Throat STIs are a thing
STIs don’t just infect someone’s genitals; they can also infect someone’s throat. (Joy.) In this case, the person probably won’t have symptoms and thus won’t know they have an infection.
But that’s not good, because someone who has an STI in their throat can pass it to someone else during oral sex.
Researchers still don’t know much about how throat STIs spread, but it’s become a big enough concern that last year the U.S. Food and Drug Administration approved the first “extragenital” tests (aka tests for the rectum and throat) for chlamydia and gonorrhea.
Those aren’t the only STIs that can spread through oral sex, though. Trichomoniasis, herpes, HPV and syphilis can all spread this way. (STIs can also spread through anal sex.)
The best way to protect against throat STIs is to use condoms or dental dams when you give or receive oral sex.
STI screening doesn’t test for everything
Say you go to your doctor’s office and ask to be screened for STIs. That means you’ll get tested for every STI under the sun, right?
Actually, no.
Different screenings involve different procedures. Screening for chlamydia and gonorrhea requires either a urine sample or genital swab. For herpes, which is notoriously difficult to diagnose, doctors may get a tissue sample or do a blood test, but the test may not be accurate. A blood test is the best way to detect HIV or syphilis, however.
People with vaginas can be tested for HPV via a Pap smear and a special HPV test which involves collecting a sample of your cervical cells. The same test can be used for people with penises, but it isn’t federally approved yet, so if you have a penis and are concerned about HPV you need to bring that up.
Typically, doctors will screen you for what you’re most at risk for depending on your sexual history: who you’ve had sex with recently and how you’ve had sex.
If you’re worried about a specific STI and want to be tested for it, you need to say so.
Some STIs are becoming antibiotic resistant
Around the world, STIs are developing resistance to the antibiotics used to treat them. Though this isn’t yet a huge threat in the United States, researchers are worried it soon could be.
Though some common STIs like chlamydia and syphilis have shown occasional antibiotic resistance, currently the biggest threat is antibiotic-resistant gonorrhea, which the CDC has declared as an urgent threat.
Gonorrhea bacteria have fairly quickly developed resistance to nearly every antibiotic used to kill them. There is only one class of drugs called cephalosporins that are still largely effective — but gonorrhea is starting to become resistant to those medications, too.
Barbee studies antibiotic-resistant gonorrhea and has come to realize, along with others in the research community, that the bacteria have a unique way of hiding out in the body and avoiding detection. They do this by infecting a person’s throat.
“Research is starting to show that gonorrhea in the throat is more common that we think. Work from a group in Australia suggests that gonorrhea may be passed through kissing only, though it’s probably rare,” Barbee says.
Researchers are also trying to learn more about an STI called Mycoplasma genitalium, which has shown to easily acquire resistance to antibiotics — and there are only a few antibiotics available to treat it. Because of this, the CDC has listed it as an emerging threat.
M. genitalium is becoming more common and is often associated with pelvic inflammatory disease, though there is still a lot scientists don’t know about it.
Testing recommendations vary — a lot
The CDC especially recommends annual screening for young women as well as gay and bisexual men, since people in those populations face a higher STI burden and are at risk for more serious complications if STIs go untreated.
But specific screening recommendations often depend on someone’s particular sexual behaviors and risk factors. There’s no one-size-fits-all approach.
For example, women who have sex with women are generally thought to have a lower STI risk overall but could face unique issues like a lessened but largely unrecognized HPV risk. (Or, hello, throat gonorrhea.)
The best way to prevent STIs is a two-step process: practice safe sex by using condoms and dental dams, then get tested regularly.
“Condoms are most important for preventing the actual acquisition of the infection, while screening regularly helps prevent unintended consequences of an infection,” Barbee explains.
So, what exactly does “regular” screening mean? If you’re sexually active but have a new sex partner or aren’t in a monogamous relationship, getting tested at least once a year is a good place to start. If you have multiple partners, getting tested more frequently might make sense.
If you want specific testing recommendations based on your unique risk factors, Planned Parenthood has a useful online tool that helps you determine if you need to get tested.
Editor's note: This article was updated on February 25, 2020, to clarify that "extragenital testing" for STIs means testing the rectum and/or throat, and that STIs can also spread through anal sex.
