A new report has found an alarming rise in sexually transmitted diseases. Fiona Tyrrell reports
An upsurge in risky sexual behaviour, changes in social mores and earlier sexual initiation are just some of the causes of an unprecedented rise in sexually transmitted infections (STIs) in Ireland.
A report published last week described the "staggering" increase in STIs in Ireland: in the decade between 1994 and 2003 there was a 174 per cent increase in notified STIs. Chlamydia, which can lead to infertility, increased by 1,044 per cent between 1995 and 2004, rising by 21 per cent between 2003 and 2004 alone.
While these dramatic hikes are partly due to increased awareness and screening as well as more sensitive diagnostic methods, they also reflect changes in sexual behaviour and increased high-risk sexual activity.
Worryingly, experts believe these headline figures represent a massive underestimation of the real incidence of STIs due to the lack of a comprehensive surveillance system.
STI surveillance in Ireland is still mainly carried out by sexual health clinics, with many GP practices and laboratories still not feeding into the national surveillance system. In addition, many STIs are asymptomatic, greatly adding to the underestimation of the problem. Chlamydia, for example, is asymptomatic in almost all women and most men.
Ireland, however, is not alone in experiencing this rise in STI rates. Similar increases are being seen throughout Europe. Irish STI figures are still low by international standards and the sharp increase being experienced now is a reflection of recent changes in Irish sexual behaviour.
Research suggests that this rise is due to a combination of social factors such as decreased marriage, delayed childbirth and population movements, as well as behavioural factors including earlier sexual initiation and worsening high-risk behaviours.
While dramatic changes in Irish attitudes to sex have been positive for the most part, there are some challenges, particularly for younger people, according to Geraldine Luddy from the Women's Health Council, which published Women and Sexually Transmitted Diseases: A Gendered Approach last week.
Young people experience much greater pressure to engage in sex at younger ages. The average age of first sex is now 15.5 years. Some 40 per cent of young men and 16 per cent of young women are now becoming sexually active prior to the legal age of consent.
At this age, they may not be emotionally or physically equipped to deal with the possible negative repercussions and are less prepared to negotiate the sex act in a manner that protects them from STIs, she says.
Last year, the National Maternity Hospital reported a chlamydia rate of 16 per cent among women younger than 20 years of age. This figure fell to 9 per cent for women under the age of 25.
Overall, 56 per cent of noted STIs occurred in people aged between 20 and 29 years of age.
Social shifts such as delays in permanent relationships, loneliness and increased sexual opportunities are among some of the reasons behind the steady increase in STIs in Ireland, according to Dr Derek Freedman, a genito-urinary physician who has a practice in Ranelagh, Dublin and is attached to St James's Hospital.
The complete dilution of traditional social structures and the fact that this generation of parents are in "no position to wag the moral finger" are also part of the problem, he says.
The arrival of thousands of new migrants aged between 20 and 40 is also a factor, he says.
In addition to all this, there is the influence of alcohol, which Freedman describes as "the great relaxer of inhibitions and great inducer of unintended sex".
An Irish survey in 2004 revealed that 45 per cent of men and 26 per cent of women admitted that alcohol had contributed to them having sex without using contraception.
Although people are beginning to sit up and take note of the STI problem, there is still denial, according to Freedman.
He says he still comes across many cases where the patient has initially presented to a GP with symptoms suggestive of an STI, but a full sexual history is never taken.
GPs are reluctant to take a full sexual history because of embarrassment or lack of training, he says.
Freedman also stresses the importance of taking the full range of seven to eight STI tests: "Once you are at risk from one disease, you are at risk for the lot."
Misdiagnosis and prescription of antibiotics and drugs to treat "thrush", for example, can result in infections being masked, according to Freedman.
While most STIs are very treatable, avoiding infection is preferable: "If you want to avoid infection, know the name of the person you're with, get a mobile number, start off with a condom and always remember that alcohol is the great loosener."
Meanwhile, Luddy has called for the formulation of an Irish sexual health strategy "as a matter of urgency".
To date, relevant data in the area has been "scant", according to Luddy. However, the forthcoming publication of the first Irish survey of sexual knowledge and behaviour next month should go some way in addressing this lack of up-to-date information. This survey must be followed by fully resourced national sexual health strategy, she says.
Signs and symptoms of various STIs
While socially embarrassing, STIs can be easily treated and managed once identified early. If ignored, some can result in cervical cancer or infertility - 20 per cent of cases of infertility are as a result of STIs.
Signs and symptoms of various STIs
Ano-genital warts: Ano-genital warts account for 39 per cent of the total number of STIs notified in 2004. Caused by certain types of the human papillomavirus virus (HPV), they usually first appear as small, painless bumps in, on or around the vagina, anus, penis or scrotum and usually appear within weeks or months of sexual contact with a person infected with HPV.
Most strains of HPV are benign but some are known to contribute to invasive cervical cancer. Most people are exposed to the HPV virus at some time or other and in most the infection is silent and transient.
Treatment usually involves destroying the lesion, usually by freezing. The virus is cleared in a couple of months, but in some cases can take considerably longer.
Chlamydia: In 2004, 2,803 cases of chlamydia were noted by STI clinics and GPs in Ireland. It is the most common STI among women and the third most common among men.
Chlamydia is caused by the bacterium, Chlamydia trachomatis. There are no reliable clinical signs. If chlamydia is not treated in women it can occasionally spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID), which can result in ectopic pregnancies, chronic pelvic pain and infertility. In men, complications are rare but untreated chlamydia infection can lead to sterility. Uncomplicated chlamydial infection can be treated and cured with antibiotics.
Gonorrhoea: Some 270 cases of gonorrhoea were noted in 2004. It is a curable sexually transmitted infection caused by the bacterium neisseria. Clinical signs may include mucosal inflammation of the urogenital tract, throat and rectum. Serious complications can occasionally occur if infections are not treated. Antibiotic-resistant gonorrhoea is almost the norm in Ireland, but it may be treated with a special antibiotic.
Non-gonococcal urethritis: Inflammation of the male urethra caused by an organism other than gonorrhoea. The commonest male infection, it usually means urethritis caused by neither gonorrhoea or chlamydia trachomatis. The symptoms may be of a stinging pain at the tip of the penis, or a discharge. It responds well to the right treatment, even if the cause is not known.
Genital herpes: Genital herpes simplex is a treatable sexually transmitted infection caused by the herpes simplex virus (HSV). In the Republic, 411 cases were noted in 2004. There are two distinct subtypes of HSV.
Type 2 is most commonly associated with genital infection.
Type 1 causes 50 per cent of genital infections, but most frequently causes oral cold sores. More than 80 per cent of individuals experience no symptoms whatsoever or mild symptoms. If present, symptoms include one or more blisters/inflammations at the site of infection and a burning sensation.