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Gender Differences in Bacterial STIs in Canada

Tom Wong MD, MPH, FRCPC (Health Canada); Ameeta Singh, BMBS (Alberta Health and Wellness); Janice Mann, MD; Lisa Hansen, MSc, MHSc; and Sharon McMahon, MA (Health Canada)

Health Issue

The incidence of bacterial sexually transmitted infections (STIs) is rising in Canada, and has serious health and economic consequences. In 1990, the estimated direct and indirect costs of chlamydia in Canadian females were as high as $115 million (CAD); for males the cost was up to $8 million. In the same year, the cost burden of gonorrhea was up to $63 million for females and $12 million for males. If these easily curable illnesses were properly prevented and treated, the cost savings would be enormous. Sexually transmitted infections pose a greater risk to women than men in a number of ways, including women's increased susceptibility to infection and the severity of the sequelae associated with infection. A further difference between men and women lies in the difficulties involved in screening and diagnosis. This chapter analyzes these differences using national STI surveillance trend data from 1991 to 2000.

Key Findings

Reported incidence rates of chlamydia, gonorrhea, and infectious syphilis declined until 1997, when this downward trend for all three STIs began to reverse. While incidence of STIs has increased for both men and women, men are experiencing a greater percentage increase: between 1991 and 2000 chlamydia increased 53% among men and 27% among women; gonorrhea increased 43% among men and 32% among women; and syphilis increased 62% among men and 22% among women. The reported rate of chlamydia is much higher among women than men, whereas the reverse is true for gonorrhea and infectious syphilis.

The power differential between men and women and higher potential for women to suffer from domestic violence create barriers to women protecting themselves against STIs. Increases in high-risk sexual behaviour among men who have sex with men began to be observed after the introduction of potent antiretroviral HIV suppressive therapy in 1996, but behavioural changes in women await further research.

Data Gaps and Recommendations

The authors identified the following data gaps and made the following recommendations:

• We need to improve the surveillance system for STIs in Canada. For example:
• The reported rate may underestimate the true incidence if a lack of symptoms causes people not to present themselves for diagnosis "we need to estimate the size of the "hidden epidemic".
• We need to evaluate and monitor gender-specific behavioural changes in this "HIV antiretroviral therapy era".
• Geographic and ethnic disparities, gaps, and needs must be addressed.
• We need to develop safer, acceptable, and female-controlled methods of STI prevention, such as topical microbicides, that do not increase the risk of HIV transmission.
• More research is needed about gender-specific strategies that promote safer sexual practices and behaviour change (e.g. the use of the Internet for STI/HIV "cyberprevention").
• Urine screening for chlamydia should be more widely available.
• We need to increase screening opportunities by taking advantage of women's greater tendency to present for health examinations (e.g. Pap tests).
• We need to improve screening of high-risk men in order to prevent re-infections in their partners.

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