Am Fam Physician. 2011 Feb 15;83(4):350-352.
to the editor: Regarding Dr. Brill's excellent clinical summary on urethritis in men, I would like to add two important points from a public health perspective. First, the article appropriately made note of the serious racial disparities in gonorrheal and chlamydial infection rates in the United States. However, to help prevent inappropriate and even hurtful race-based assumptions about their patients, physicians must understand the implications of applying this observation to clinical practice.
Race is not a physiologic risk factor for sexually transmitted infections (STIs). Race is a noncausal population-level association with STIs. A black man in a monogamous relationship is at no greater risk of acquiring an STI than a white man in a monogamous relationship. It is the behavior of the patient and his or her partner(s) that determine risk, not the patient's race.
This is a subtle but important point. One could argue that because the burden of disease is much greater in the black population, the risk of exposure must be greater as well. However, at the individual level, that may or may not be true. Estimating the actual risk requires a careful and individualized risk assessment of the patient and his specific partner(s) and behaviors, not an assumption on the basis of skin color.
Second, as many as 10 percent of men with genital gonococcal infection may be asymptomatic,1 and other studies suggest even higher rates of asymptomatic infection. With this in mind, physicians should not rule out gonorrheal infection in high-risk patients just because they are symptom-free.
Likewise, although general screening of men for STIs (and women for gonorrhea) is not recommended, screening asymptomatic patients may be appropriate in certain circumstances or in certain higher-risk settings. The Milwaukee Health Department has an example of local recommendations.2 In fact, the U.S. Preventive Services Task Force suggests that physicians “may want to consider other population-based risk factors, including residence in urban communities and communities with high rates of poverty, when making screening decisions” for gonorrheal infection.3 The 2006 Centers for Disease Control and Prevention's sexually transmitted diseases treatment guidelines state that “screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia.”4
I strongly encourage physicians working with high-risk patients or in communities with a high prevalence of STIs to not use race as a proxy for individual risk, and to consult with local public health officials regarding local recommendations for screening men, and women, for chlamydial and gonorrheal infection.
1. Bignell C; IUSTI/WHO. 2009 European (IUSTI/WHO) guideline on the diagnosis and treatment of gonorrhoea in adults. Int J STD AIDS. 2009;20(7):453–457.
2. MSMC Community Collaboration on Healthcare Quality (CCHQ) and the City of Milwaukee Health Department (MHD). Sexually transmitted diseases in Milwaukee County and other high risk areas: screening, testing and treatment recommendations. http://www.milwaukee.gov/ImageLibrary/Groups/healthAuthors/DCP/PDFs/STD_Screen_Tx_Guide_updated_20080121.pdf.
3. US Preventive Services Task Force. Screening for gonorrhea: recommendation statement. Rockville, Md.: Agency for Healthcare Research and Quality; May 2005. AHRQ publication no. 05-0579-A. http://www.ahrq.gov/clinic/uspstf05/gonorrhea/gonrs.htm. Accessed July 12, 2010.
4. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006 [published correction appears in MMWR Recomm Rep. 2006;55(36):997]. MMWR Recomm Rep. 2006;55(RR-11):1–94.
in reply: I appreciate and agree with Dr. Swain's comments. Although an overall awareness of epidemiology is important, we need to treat the patient in front of us as an individual. Family physicians should also be mindful of sexually transmitted infection patterns in their communities, and local public health departments are excellent resources for helping to tailor treatment plans.
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