It's not often that you encounter a graph and you think, "Wow! My god, that is a spectacular graph!" I have such a graph for you, reader, and it just so happens to be about gonorrhea. I know what you're thinking, "she can really pick 'em, huh? Exceptional taste in data presentation."
Truly though, this graph is a wonderful piece of historical data, a beautiful 2-D chart that plainly illustrates a few of the major social and cultural forces that have occurred in the United States this past century. Namely, the Second World War, the emergence of the Baby Boomer generation and the sexual revolution. This is heavy-duty stuff, people!
Rates of Gonorrhea in the United States, from 1941 to 2010. Image: CDC. Click for Source.
Let's look at this baby.
From 1941 to 1947, the rates of gonorrheal infection in the American population increased during and after the Second World War. Reported cases reached a peak of roughly 400,000 and fell as soldiers were re-integrated into the American society (1).
American men and women were mighty busy after the war. The United States saw an increased birth rate from 1946 to 1964 that today we view a demographic explosion or "boom" - the Baby Boomers arrived, one of the "largest generations in US history" (2). Gonorrhea laid low during this period, returning to pre-war levels as Americans committed themselves to their new families as well as a revitalized economy and a rapidly changing society.
"You can't beat the Axis if you get VD!" A public health poster dating from 1942-1945 targeting American soldiers. Blaming women for the spread of these STDs certainly seems unfair but, in the case of gonorrhea, women are largely asymptomatic for the disease whereas men usually suffer symptoms quite acutely. STDs spread easily when people don't know they're infected (See: HIV/AIDS crisis.) Image: Public Domain. Click for source.
Twenty odd years later, from the 1960s to the 1970s, those Baby Boomers hit sexual maturity and a massive sexually active population became vulnerable to existing sexually transmitted diseases. This generational coming-of-age coincided with the women's liberation movement and the sexual revolution, two incredibly powerful cultural forces that, together, triggered profound changes in American sexual mores and behavior (3).
Amidst this slackening of traditional sexual mores and the expansion of social and sexual freedom in this population, oral contraceptives and intrauterine devices (IUDs) fortuitously hit the market. (You see where this is going, right?) An article I dredged up from 1985 dryly states that the "use of non-barrier methods of contraception increased steadily from the early 1960s to the mid-1970s" (4). Indeed - in a very short five years, the number of women taking the Pill increased from nearly zero to 6 million (5). Did the widespread availability of reliable birth control have an effect upon sexual practices?
You bet it did. Both the spirit and the flesh were willing. Surveys conducted in the late '60s and throughout the '70s found that the proportion of young women having premarital sex rocketed by 300% compared to a rather measly 50% increase in men (4).
Consulting my epidemiological cookbook for a moment in search of a recipe for a perfect STD epidemic, I see that it calls for one part population explosion, two parts available contraceptives, and a healthy serving of loosening sexual taboos and heightened sense of individualization — be sure to add in increased rates of drug experimentation, if you have any handy in the kitchen. Shake with ice and strain into a martini glass. Serve with the Cuban Missile Crisis, the Woodstock festival and a dude walking on the moon. Will make hundreds of thousands of gonorrhea cases/servings per year (1).
You can see in the graph that the gonorrhea epidemic unquestionably started in the 1960s, increasing in scope until it peaked in 1976. That year, the number of cases diagnosed hit at just over one million (6). It would be near impossible to disentangle the exact effects these macro social and cultural forces - the demographic blip that was the baby boomers, women's liberation, and contraceptives geared towards women - had on the increasing rates of gonorrhea in this period and on influencing each other. It would be easy to say that women's lib and contraceptives increased the rate of gonorrheal infection, but really it can only be proven to be a positive correlation.
Certainly, some of the increasing rates can be attributed to the improvement of the surveillance and reporting systems for STDs. Our ability to diagnose them in clinics has become more sophisticated thanks to advances in biotechnology and the rates of gonorrhea increased because our health system got better at detecting asymptomatic, under-the-radar infections.
This is one of three public health posters made by the Health Education Council in the United Kingdom in 1969 emphasizing the importance of contraception. By addressing the taboo of premarital sex, contraception and out-of-wedlock pregnancy, as well as subverting the masculinity of men, they were considered wildly shocking at the time. Image: Health Education Council, United Kingdom. Click for source.
What happened in the mid-1970s that led to the decline of gonorrhea? One of the best explanations is that the numbers of people in the 18-24 age class, a group that has historically always had the highest incidence and prevalence of gonorrhea, began to decline as the Baby Boomer population aged out. Those 76 million people had to move onto their thirties at some point and so, as free love and communal living gave way to what Tom Wolfe famously called the "Me" Decade, they did. Another explanation is that condoms began to be commonly substituted for non-barrier contraceptives, offering a physical barrier against disease transmission (4).
In 1973, the country also got around to implementing a national gonorrhea control program that would both enhance surveillance and diagnosis of the disease. Financed by the CDC, state health departments began providing laboratory services to physicians specifying that all women in the "reproductive age group" should be screened for the disease (7). Why women, you ask? The disease is usually asymptomatic in the ladies and monitoring the infection is one of the best ways to halt transmission. This screening program would eventually lead to detecting a full third of all reported cases of the infection in women from 1973 to 1975 (8). In another 25 years, the gonorrheal rate would crash down to just 74% of its peak rate in 1976, below its pre-war levels.
Today, gonorrhea still remains a significant public problem. It ranks as the second most commonly reported bacterial STD in the States and the CDC estimates that over 700,000 people pick up this infection every year (9). It is a particular scourge in the African-American community, accounting for nearly 70% of all diagnosed cases of gonorrhea (10). Gonorrhea now has 'Superbug' status and is now largely resistant to every antibiotic we've got left. We will be seeing a lot more of this guy and this graph will soon change again. Americans are still rocking the (sexual) revolution in all its glory and sorrow.
I'm focusing on the American sexual revolution and women's liberation here, but the same can most certainly be said for other developed countries in the 1940s to 1970s. For example, the data suggests the exact same epidemiological scenario for England. My apologies to my international readers for this myopic focus on American epidemiology, our data is just so good!
One of the references I use, see below, is an article on Alternet that is actually an excerpt from the book "Delirium: How the Sexual Counterrevolution is Polarizing America" by Nancy L. Cohen. You can purchase the book here.
Once gonorrhea was exiting the stage, HIV/AIDS was making their big entrance. I wrote about hip-hop and RnB artists singing about HIV and STDs in this article "Let’s Talk About Sex" right here. There's an included playlist! Listen to it at work and reflect on the global HIV/AIDS crisis! Anyone? Anyone?
(1) Cornelius CE. (1971) Seasonality of Gonorrhea in the United States. HSMHA Health Reports. 86(2): 157-60 (2) U.S. Census Bureau. (2011) 2010 Census Briefs: The Older Population: 2010. United States Census 2010 (http://2010.census.gov). Accessed September 21, 2012 here. (3) Maurer DW. (1976) Language and the Sex Revolution: World War I through World War II. American Speech.51(1/2): 5-24 (4) Hook EW. (1985) Gonococcal infections. Annals of Internal Medicine. 102(2): 229-243 (5) Cohen NL. (2012) How the Sexual Revolution Changed America Forever. AlterNet (http://www.alternet.org/) Accessed September 21, 2012 here. (6) Centers for Disease Control & Prevention (2011) Gonorrhea. Sexually Transmitted Disease Surveillance, 2010. Accessed September 21, 2012 here. (7) Balows A and Printz DW (1972) CDC Program for Diagnosis of Gonorrhea. JAMA. 222(12): 1557-1557 (8) Yorke JA, Hethcote HW and Nold A. (1978) Dynamics and control of the transmission of gonorrhea. Sex Transm Dis. 5(2): 51-6 (9) Centers for Disease Control & Prevention (2012) Gonorrhea - CDC Fact Sheet. Sexually Transmitted Diseases (STD). Accessed September 24, 2012 here. (10) Centers for Disease Control & Prevention (2011) African Americans/Black. Disparities in HIV/AIDS, Viral Hepatitis, STDs, and TB. Accessed September 24, 2012 here.
orke JA, Hethcote HW and Nold A. (1978). Dynamics and control of the transmission of gonorrhea. Sex Transm Dis. DOI: 10.1097/00007435-197804000-00003