How online dating fuelled record level of STIs in Britain

If you wanted to chart the history of the nation over the last century, one way would be to look at the rise and fall of two sexually transmitted infections: gonorrhoea and syphilis.

The UK has been collecting data on the two diseases since 1916 when the Royal Commission on Venereal Disease recommended the establishment of state-funded treatment clinics and a programme of “moral instruction” to combat the “hideous scourge” sweeping the nation. 

Since then, diagnoses of gonorrhoea and syphilis have waxed and waned, reflecting social, economic and technological trends. 

Cases spiked during both the First and Second World Wars as the more rigid sexual attitudes of peacetime were discarded and the number of sexual partners increased and then declined as troops returned home. After the Second World War, cases fell particularly sharply as the antibiotic penicillin became available on a large scale for the first time.

The swinging ‘60s brought another resurgence, before the Aids panic of the 1980s and 1990s – when strict condom use and even sexual abstinence was practised – drove the diseases to historically low levels.

Today, though, cases of gonorrhoea are now at their highest level since records began in 1918, standing at more than 82,500 cases in 2022. The annual number of cases of syphilis, a disease once thought consigned to history, have meanwhile doubled over the past decade and last year reached 8,700.

Neither disease is pleasant. Gonorrhoea symptoms include discharge from the vagina or penis and bleeding between periods for women. Around one in 10 people do not have symptoms, enabling it to spread, and, if left untreated, the infection can lead to infertility. 

Syphilis is more complex. Initially patients may find a small sore on their penis, vagina or anus. Without treatment, this can lead to the development of rashes. Serious complications, such as neurological damage and heart complaints, can emerge even decades later. 

So how is it that both infections have bounced back from relative obscurity in the UK?

Broader tastes with more partners

The “broadening of sexual repertoires” over the past 30 years, as seen in the National Survey of Sexual Attitudes and Lifestyles (Natsal), is certainly one explanation.

The survey – which has collected data on the bedroom activities of the nation every 10 years since the late 1980s – shows that the UK population has become liberal and accepting of non-monogamous relationships. Homosexuality has also been normalised, it shows.

Crucially, the number of partners people say they have had over their lifetime has also increased, according to the survey. 

In 1990-91, women aged 16-44 reported an average of 3.7 opposite sex partners, rising to 7.7 two decades later. For men, the picture is slightly different – they had an average of 8.6 opposite sex partners in 1990, then 12.6 in 2000 before dropping to 11.7 in 2010. 

“Between 2000 and 2010 we saw big changes for young people – particularly young women – in the types of behaviour they were engaging in,” says Soazig Clifton, academic director of Natsal. “Young women were reporting more partners, more same sex partners and more anal sex.”

Since 2010, digital technology in the form of dating apps and sexting has had a huge impact on people’s sex lives – and the next survey will encompass this for the first time, says Ms Clifton. 

“We hardly touched on this in the previous surveys and this is a big area since 2010. So that includes things like pornography. It also includes meeting partners online via apps or websites, as well as sexting,” she adds.

Emma Harding-Esch, an epidemiologist in STIs at the London School of Hygiene and Tropical Medicine, agrees that dating apps enable people to find quick and local hook-ups, meaning there is a much wider pool of potential sexual partners than for previous generations. The increase in international travel has also played a part.

Then there is development of pre-exposure prophylaxis (PrEP) to consider. Consumed as a pill, it is taken by people considered at risk of HIV infection before and after sex to reduce their chances of contracting the virus. It is freely available in England, Wales and Scotland.

Many public health experts believe this game-changing drug has led to a huge increase in unprotected sex among men who have sex with men. 

One study looking at trends in bacterial STIs in Bristol, published in the journal Sexually Transmitted Infections, found that the proportion of men having unprotected sex with other men rose from 40.6 per cent to 45.5 per cent between 2016 and 2019 as PrEP became more widely available. The average number of partners increased from 3.8 to 4.5.

The researchers also found that men had more STI tests over the study period – up from an average of 1.5 a year to 2.1 a year. Gonorrhoea, syphilis and chlamydia make up a large proportion of these positive diagnoses.

The increase in unprotected sex and number of partners may be down to “evolving sexual decision making among PrEP users and their partners,” the researchers concluded.

Although PrEP has had the biggest impact among men who have sex with men, the effects have also rippled out to the broader community as some of these men will also have sex with women. 

“Greater sexual contact numbers means larger sexual networks, facilitating transmission of STIs from key and vulnerable populations to the general population,” says Dr Harding-Esch. 

Daniel Richardson, clinical professor of sexual health and HIV medicine at Brighton and Sussex Medical School, agrees that sexual behaviour and social practices are changing, particularly among young people who are at the highest risk of contracting STIs. 

“People are having more sex with drugs which lowers their inhibitions and they are more fluid about their behaviour in terms of having sex with either the opposite sex or the same sex,” he says.

Last month, the UK Health Security Agency warned university students to make sure they use condoms if having sex with someone new as rates of gonorrhoea are sharply rising in the under-24s. 

This warning comes amid evidence that suggests use of the latex contraceptive is in decline. In the US, annual surveys of risky behaviour among high school students shows that condom use has fallen over the past 20 years. Just 51.8 per cent of those surveyed in 2021 said they had used a condom last time they had sex, compared to 63 per cent in 2003. 

Yet Dr Doherty at the WHO says that public health experts need to look at ways of preventing STIs beyond condoms. 

One development that has shown promise is the administration of a common antibiotic, doxycycline, after sex – a kind of morning-after pill for STIs. 

A recent study of 500 men who have sex with men found that those who took doxycycline after condomless sex were 60 per cent less likely to contract gonorrhoea, syphilis or chlamydia than those who did not take the pill.

However, the idea of administering broad spectrum antibiotics on a large scale could have worrying implications for antibiotic resistance. Prof Richardson agrees that there are “a lot of unknowns” and that there would have to be rigorous protocols. 

“But we have this terrible epidemic of syphilis and gonorrhoea so this could work in a core group of people who are having multiple infections,” he said.  

Gonorrhoea is rapidly developing resistance to antibiotics, raising fears that it may one day be untreatable. 

In 2018, the UK saw what health authorities called the “world’s worst case” of the disease, contracted by a man while travelling in south east Asia. He required three days of intravenous drug treatment rather than the usual injection. 

Vaccine candidates are in development and there has been some early success; however, because people do not develop immunity to the bacteria it is unlikely that a jab would offer long-term protection.

But while all this may give the impression that the sexually active among us are enjoying a hedonistic revolution between the sheets, the Natsal survey has some counterintuitive findings: people are actually having less sex than previous generations.

In the 1990 survey, people said they had sex five times a month; in 2000, it was four times a month, and down to just three times in the 2010 survey.

“We were a bit taken aback when we saw that trend, but since then other countries around the world have reported the same thing,” says Ms Clifton. “So although people might be broadening the types of sex they’re having and with whom, it looks like overall people are having less sex.”

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