Analysis Sexual Health

No Clapping Matter: Antibiotic-Resistant Gonorrhea Is On the Way and We Are Not Prepared

Martha Kempner

For years, even those in the public heath community paid little attention to gonorrhea because it was easy to prevent, easy to screen for, and easy to treat—at least it was until now. Gonorrhea is caused by wily bacteria that has become resistant to all-but-one class of antibiotics and we don't have any others to throw at it. It's time to take start taking notice.

When I was a peer sexuality educator at UMASS-Amherst back in the early 1990s we used to joke about the fact that the only gynecologist on staff at the health center was named Dr. Daniel Clap. At the time it seemed hilarious that the man charged with prescribing our pills and diagnosing our sexually transmitted diseases (STDs) seemed to be named after one of the most common STDs. None of us knew why gonorrhea was called the clap (more on that later). In truth, apart from making the joke about the gynecologist’s name, none of us thought much about this bacterial infection that had been reduced a nuisance by the advent of antibiotics long before we were born. Sure, we stressed how condoms can prevent gonorrhea and how important it was to get tested for it because it often has no symptoms but in the workshops we led we paid far more attention to the “4-H club” because these diseases—HPV, HIV, Hepatitis B, and Herpes—were ones you might have to live with for the rest of your life.    

We were not alone in our complacency around gonorrhea. The disease is easily prevented by condoms, easily tested for in STD clinics, and easily cured. HIV got attention for being potentially life threatening. HPV got attention for being so widespread and leading to cervical cancer. Gonorrhea was annoying but not much of a menace. Deborah Arrindell, Vice President, Health Policy for the American Social Health Association (ASHA), explained it this way:

“We think of gonorrhea as a funny infection—the clap—that doesn’t kill anybody.  But the consequences of untreated gonorrhea are quite serious; infertility, increased risk of HIV, and a big impact on our national wallet…nothing to clap about there.”

Today, many in the public health community will admit that we collectively took our eyes off the ball because Neisseria gonorrhoeae is a very clever bug that has developed the ability to resist nearly all of the antibiotics that have been thrown in its path. It has steadily developed resistance to entire classes of antibiotics—as early as the 1940s it was resistant to sulfanilamides, by the 1980s penicillins and tetracyclines no longer worked, and in 2007 the CDC stopped recommending the use of fluoroquinolones (the class of drugs that includes Cipro, which we may all remember as the thing to stockpile in case of an anthrax attack). Today, the only class of antibiotics that remains effective are cephalosporins, but its susceptibility to these drugs is declining rapidly in the United States and other countries have already seen cephalosporin-resistant cases. 

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In February the Centers for Disease Control and Prevention (CDC) sounded the alarm about this growing threat and suggested that we need to change the way we screen for and treat gonorrhea in this country in order to respond to this wily germ. Last week, the World Health Organization (WHO) released a statement  on this issue and, more importantly, a global action plan for stemming the spread of drug-resistant gonorrhea. As the resistant cases emerge, it is a good time to look at how we got here and what we can do to ensure that gonorrhea does not become a major public health threat.

Cephalosporin-Resistant Gonorrhea is Coming

Physicians in southern Japan saw their first case of gonorrhea that was less susceptible to the usual cephalosporin drug regimen as early as 1999. Sweden followed in 2002, England in 2005, and Norway in 2010. Many of these cases seem to originate in Japan. For example, in 2010 a Swedish man contracted gonorrhea from a woman he met on a trip to Japan. He required four times the standard dose of cefitriaxone to eradicate the bacteria.  The following year, Japanese researchers announced that a sex worker in Kyoto was infected with a “highly resistant” strain that was cured only after multiple intravenous antibiotics. A similar case was reported in France.

Here, the CDC began the Gonococcal Isolate Surveillance Project (GISP) to monitor trends in antimicrobial resistance of gonorrhea in 1986. For this project, isolates are collected from the first 25 men with urethral gonorrhea attending STD clinics each month in approximately 28 cities in the United States. These isolates are then tested at one of four or five regional laboratories to determine their susceptibility to penicillin, tetracycline, spectinomycin, ciprofloxacin, ceftriaxone, cefixime, and azithromycin.  The results of these tests have been used to assess the threat and change treatment guidelines numerous times as resistance to various drugs emerged.   

There have not yet been any treatment failures in the United States but the occurrence of partial resistance to cephalosporins (meaning that the drugs only succumb to unusually high doses) has increased 17 percent since 2006.  In addition, GISP tested 5,900 samples of bacteria from around the country and found that 1.4 percent of them had diminished susceptibility to cephalosporins.

In a February editorial in the New England Journal of Medicine, Dr. Gail Bolan of the CDC pointed out that the pattern of declining cephalosporin susceptibility is reminiscent of the emergence of fluoroquinolone-resistant gonorrhea less than a decade ago.  She concluded:

“We should anticipate the emergence of fit cephalosporin-resistant strains that can spread widely.”

Holes in the System

Gonorrhea is a widespread problem. With an estimated 600,000 new cases per year, it ranks as the second-most reported infectious disease in the United States. (Chlamydia is the first.) Still, until recently few people worried about it because both screening and treatment were easy and relatively inexpensive—important factors in the control of STDs. 

For many years now, a patient who comes to an STD clinic is tested for gonorrhea using a sample of the patient’s urine and something called a Nucleic Acid Amplification Test (NAAT).  These tests are simple to do and inexpensive to run and give you a lot of “bang for your buck” as it costs only $2 more to run a test for both gonorrhea and Chlamydia at the same time.  If a patient tested positive for gonorrhea today, he or she would be given one injected dose of ceftriaxone (a cephalosporin) and would take home a seven day course of either azithromycin or doxycycline.  If the health care provider was not set up to give an injection, the dose of ceftriaxone could be given orally instead.  For the majority of individuals that would be the end of their interaction with a health care provider—most often there is no further tracking of the patient and no re-tests to ensure that the infection is really gone. Patients and providers alike simply assume the infection has been cured by the antibiotics despite the fact that gonorrhea is often asymptomatic.  If a patient returned to the clinic with symptoms, it is likely that the health care provider would assume a new infection and start over. 

This structure has been great in many ways because it has allowed for widespread screening and treatment which is one of the most effective ways to stop the spread of disease. As cases of antibiotic-resistant gonorrhea emerge, however, it is becoming clear that there are problems with what we’ve done and holes in the system that will make it harder to address the disease moving forward.

The first problem is that we don’t test everywhere the bacteria are likely to live. The urine test is essentially a genital sample.  It can tell whether an individual has gonorrhea in his/her urethra or cervix. But gonorrhea can also be spread to the throat and the anus during oral and anal sex. Men who have sex with men (MSM) are especially likely to have infections in these areas.  A 2003 study of gay and bisexual men in the San Francisco area illustrates the problem. Participants were screened for Chlamydia and gonorrhea in their throat, urethra, and anus. The study found that if this population had only been given the urine test or urethral swabs, 53 percent of the Chlamydia cases and 64 percent of the gonorrhea cases would have been missed.  Limiting screening to urine tests not only misses the opportunity to treat the individual in front of you but also allows these individuals to unknowingly spread the infection to others.  Moreover, some public health professionals believe that years of undiagnosed infections of the throat is part of what allowed gonorrhea—which adapts by borrowing DNA from other bacteria and organisms—to become resistant in the first place. (Other reasons include over-use and misuse of antibiotics and anti-microbials both in treating medical problems and in our day-to-day life.)  

The second problem is that while NAAT tests are inexpensive and simple, they don’t uncover all of the information we need.  In order to determine if a patient is infected with a resistant strain, health care providers would have to swab the potentially infected area and use a culture to grow the bacteria.  (I’m picturing the giant q-tip and red petri dish that Killer Kleckner, the nurse at Warensdorfer school, used to test us for strep throat.)  Most providers—even those who regularly screen for STDs—are not set up to do this.  From discomfort with the swabbing process, to a lack of training  on how to culture, to a dearth of laboratories set up to run such cultures, to the transportation required to get the samples to the lab—many pieces of this puzzle are missing.  As William Smith, executive director of the National Coalition of STD Directors (NCSD) explains:

“We’ve lost our ability to culture.”

I casually asked my pediatrician about how he tests for gonorrhea (because what mother who brings in her 21-month old for a cough doesn’t inquire about that) and he said he can do the urine test but isn’t set up to do cultures.  He added that he might swab the urethra of teenage boy but would automatically send a young woman to a gynecologist.  Moreover, he said that while he knows how to do culture by virtue of his age, he is pretty sure that individuals just a few years behind him in training would have never been taught that skill.

Surveillance is also a problem. Given that we now anticipate cases of gonorrhea that are resistant to cephalosporins, it is important to have a monitoring system in place that can catch these news strains quickly in order to ensure that they are not spread widely into the population.  Our current system is chronically under-funded and not prepared to do this.     

The biggest problem with how we do things now, however, is simply a lack of drugs that can work. And this problem is truly alarming because it’s just about gonorrhea anymore.

No Drugs In the Pipeline

Neisseria gonorrhoeae is part of a group of bacteria know as gram-negative because they do not retain crystal violet dye in the Gram staining protocol. These microbes can cause serious diseases, including meningitis, pneumonia, and gonorrhea, as well as infections of the blood, urinary tract, and intestines. (E-coli, for example, are gram-negative bacteria). Such bacteria are increasingly resistant to most available antibiotics. As the CDC explains, “these bacteria have built-in abilities to find new ways to be resistant and can pass along genetic materials that allow other bacteria to become drug-resistant as well.”  These are not the only bacteria that are becoming resistant to existing antibiotic—the infection known as MRSA (methicillin-resistant Staphylococcus aureus) has gotten a good deal of media attention in the past few years. Like MRSA, gram-negative infections often occur in hospital settings. One major difference, however, is that there are new drugs—some approved in just the last few years—that are effective against MRSA.  

In contrast, no new family of drugs to fight gram-negative bacteria has been introduced since the 1970s and there are no known trials in the pipeline. (After the post-9/11 anthrax scare the government did focus on development of new drugs but the results of this are not yet public.)  Pharmaceutical companies have developed stronger drugs within the same family but that does not help once bacteria become truly resistant.  A double membrane makes these bacteria harder to attack than those that are gram-positive but the real reason for a lack of new drugs seems to be less about the science and more about the money. Antibiotics are not money makers. Smith points out that antibiotics are relatively inexpensive and taken for a short period of time:

“Pharmaceutical companies are driven by profit and it is much more profitable to invest in the development of a drug someone is going to take for the rest of their life than something they are going to take for a week.” 

In fact, a recent analysis found that at discovery a new antibiotic would have a value of minus 50 million dollars compared to a musculoskeletal drug which has a value of one billion dollars at discovery.  The threshold for internal investment from drug companies is considered to be 200 million dollars.  So it is not surprising that these companies are simply not investing their research and development dollars here.  But it is a big problem and Smith believes that it’s time for the government to take action:

“When private enterprise isn’t doing what it needs to do to protect the public health, the role of the government is to step in. Thus far the government has failed to fulfill its responsibility to incentivize the development of good drugs.”

In a presentation for NCSD, Board Chair Dr. Peter Leone pointed out that antibiotics are unique because they are the only drugs that experience resistance that can be spread from person to person. 

“If we don’t develop any new blood pressure drugs, in 50 years the drugs we have today will still work.  If we don’t develop new antibiotics, we won’t have any effective antibiotics in 50 years.” 

Leone argues that:

“In essence, antibiotics are public health community property.”    

Progress has been made in recent weeks with the passage of the GAIN ACT, Generating Antibiotic Incentives Now Act of 2011. This legislation “seeks to increase the commercial value of antibiotics by extending the term of exclusivity granted to innovator drugs by the Food and Drug Administration (FDA).”  It also allows for a fast-track process for gaining FDA approval in an attempt to eliminate some of the uncertainty in the process which is often cited as a barrier to the development of new drugs.  The Senate and the House both passed the GAIN ACT as part of the FDA reauthorization legislation at the end of May.

While we are waiting for the government and the drug companies to begin to develop new drugs, the CDC, the NIH, and WHO are working on new treatment plans that combine existing antibiotics to better attack the bacteria.   

Change Is Needed But It Won’t Be Cheap

In addition to developing new drugs and treatment plans there are many things we can be doing to stem this looming health crisis.  We need to scale up prevention education for both providers and patients as gonorrhea is one of the STDs that is most easily preventable using condoms.  We need to develop state and local capacity to detect treatment failures and resistant strains.  STD screening sites either have to become equipped to perform cultures or enter into partnerships with laboratories that have this capability.  It might also mean that health care providers have to “test for a cure” —bring patients back post-treatment to ensure that the antibiotics worked.  Public health professionals sometimes use the term “treatment-as-prevention.”  The belief is that if we screen widely and treat those who are infected, they will not infect others.  But this only works if the treatment is effective and with increasingly resistant strains we might need to start confirming that it was. 

As Maryn McKenna, author of Superbug and a frequent writer on this topic, points out this might mean STD prevention and care is no longer inexpensive:

“… once you start bringing patients back and giving them additional and different tests, STD control becomes more costly. (That’s not even to mention the additional, distributed costs of developing new education efforts, surveillance systems or drugs.) In my read, that’s the real news in the WHO’s decision to sound a global alarm: a tacit admission that the era of cheap STD control may be over.”

The cost-benefit analysis is quite clear.  Dr. Bolan estimates that without action, the incidence of gonorrhea could increase four-fold over the next seven year to 2.4 million new cases per year.  This would likely result in 775 new case of HIV (because an active gonorrhea infection makes transmission of HIV easier) which would cost an additional $180 million dollars; 255,000 additional cases of Pelvic Inflammatory Disease in women which would cost $585 million dollars and lead to 51,000 cases of infertility; and 50,000 cases of epididymitis (inflammation of the epididymis, a tube inside the testicles) which would cost $15 million dollars. The populations that would be most affected are blacks and men who have sex with men because these communities already have the highest rates of HIV and gonorrhea. 

Still, in today’s environment in which the government is pushing for austerity even in the face of facts like these it’s hard to get more money. In fact, federal STD prevention funding has been cut by 5.8 million dollars from 159.6 million dollars in Fiscal Year 2005 to 153.8 million dollars in Fiscal Year 2012.  In addition, 69 percent of states have cut funding to their STD programs since 2008. Smith argues:

“Given everything that we now know and the looming public health disaster, now is no time to be looking at cutting budgets on the federal, state, and local level for STD screening and treatment.” 

Where’s the Public Outcry?

Every other day, my local news seems to warn me that germs are lurking everywhere—“the 10 germs in your car that make you sick, more at eleven.” I remember a few years ago when the Today Show did a week long expose using an ultraviolet light and cultures to determine what germs were lurking in hotel rooms, shopping carts, and diaper bags. Apparently, germs are everywhere and they can lead to respiratory issues and stomach aches. Uh oh. Despite this fascination with germs, I have yet to hear the mainstream media take up the rallying cry of drug-resistant gonorrhea.  If this were strep throat or one of the dozen other childhood bacteria that I have run to Walgreens to cure in my own children, we might have the kind of public outcry we did over Bird Flu or Swine Flu but this has been somewhat quiet. 

Arrindell points out that STDs have always gotten short shrift in the public discourse:

“As a nation we have a hard time talking seriously about sexual health. STDs, in particular, are considered a bad thing that happens to people who do bad things.  We blame the victim.”  

She added that:

“The disproportionate disease burden of gonorrhea is among African Americans and men who have sex with men which makes it even easier to ignore.”   

Smith reminds us, though, that gonorrhea is just the tip of the iceberg—as time goes by more bacteria will become resistant to the available antibiotics. He pointed to the media coverage of recent cases of “flesh-eating bacteria” and notes that even there the issue of growing resistance is rarely brought up.  He’s right. The stories I’ve seen about the Georgia college student who has thus far lost her left leg, her right foot, and both hands to a bacterial infection have all focused on her strength and her mood.  None emphasizes that the “flesh-eating bacteria” she contracted when she fell of a zip line is called Aeromonas hydrophila (another gram-negative bacteria), that it has resulted in multiple amputations because it is not responding to any available antibiotics, or that there are no new antibiotics in development to help the next person who gets this bug. This seems like a bigger story to me than her daily frame of mind. 

When I started discussing this article with a friend and began venting about how the public isn’t taking drug- resistant gonorrhea seriously, she said that everyone would pay more attention it made penises fall off. Well, it doesn’t quite do that but one theory of how gonorrhea got nicknamed “the Clap” is that early treatments involved doctors clapping hard on both sides of the penis, or worse, dropping a book on it, to clear the urethra of pus.

Perhaps the threat of going back to the painful old days will be enough to get policymakers, health care providers, public health experts, and drug company executives to begin working together to make sure that treatment options more sophisticated than clapping remain available. 

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Commentary Politics

No, Republicans, Porn Is Still Not a Public Health Crisis

Martha Kempner

The news of the last few weeks has been full of public health crises—gun violence, Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography.

The news of the last few weeks has been full of public health crises—gun violence, the Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography. Without much debate, a subcommittee of Republican delegates agreed to add to a draft of the party’s 2016 platform an amendment declaring pornography is endangering our children and destroying lives. As Rewire argued when Utah passed a resolution with similar language, pornography is neither dangerous nor a public health crisis.

According to CNN, the amendment to the platform reads:

The internet must not become a safe haven for predators. Pornography, with its harmful effects, especially on children, has become a public health crisis that is destroying the life [sic] of millions. We encourage states to continue to fight this public menace and pledge our commitment to children’s safety and well-being. We applaud the social networking sites that bar sex offenders from participation. We urge energetic prosecution of child pornography which [is] closely linked to human trafficking.

Mary Frances Forrester, a delegate from North Carolina, told Yahoo News in an interview that she had worked with conservative Christian group Concerned Women for America (CWA) on the amendment’s language. On its website, CWA explains that its mission is “to protect and promote Biblical values among all citizens—first through prayer, then education, and finally by influencing our society—thereby reversing the decline in moral values in our nation.”

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The amendment does not elaborate on the ways in which this internet monster is supposedly harmful to children. Forrester, however, told Yahoo News that she worries that pornography is addictive: “It’s such an insidious epidemic and there are no rules for our children. It seems … [young people] do not have the discernment and so they become addicted before they have the maturity to understand the consequences.”

“Biological” porn addiction was one of the 18 “points of fact” that were included in a Utah Senate resolution that was ultimately signed by Gov. Gary Herbert (R) in April. As Rewire explained when the resolution first passed out of committee in February, none of these “facts” are supported by scientific research.

The myth of porn addiction typically suggests that young people who view pornography and enjoy it will be hard-wired to need more and more pornography, in much the same way that a drug addict needs their next fix. The myth goes on to allege that porn addicts will not just need more porn but will need more explicit or violent porn in order to get off. This will prevent them from having healthy sexual relationships in real life, and might even lead them to become sexually violent as well.

This is a scary story, for sure, but it is not supported by research. Yes, porn does activate the same pleasure centers in the brain that are activated by, for example, cocaine or heroin. But as Nicole Prause, a researcher at the University of California, Los Angeles, told Rewire back in February, so does looking at pictures of “chocolate, cheese, or puppies playing.” Prause went on to explain: “Sex film viewing does not lead to loss of control, erectile dysfunction, enhanced cue (sex image) reactivity, or withdrawal.” Without these symptoms, she said, we can assume “sex films are not addicting.”

Though the GOP’s draft platform amendment is far less explicit about why porn is harmful than Utah’s resolution, the Republicans on the subcommittee clearly want to evoke fears of child pornography, sexual predators, and trafficking. It is as though they want us to believe that pornography on the internet is the exclusive domain of those wishing to molest or exploit our children.

Child pornography is certainly an issue, as are sexual predators and human trafficking. But conflating all those problems and treating all porn as if it worsens them across the board does nothing to solve them, and diverts attention from actual potential solutions.

David Ley, a clinical psychologist, told Rewire in a recent email that the majority of porn on the internet depicts adults. Equating all internet porn with child pornography and molestation is dangerous, Ley wrote, not just because it vilifies a perfectly healthy sexual behavior but because it takes focus away from the real dangers to children: “The modern dialogue about child porn is just a version of the stranger danger stories of men in trenchcoats in alleys—it tells kids to fear the unknown, the stranger, when in fact, 90 percent of sexual abuse of children occurs at hands of people known to the victim—relatives, wrestling coaches, teachers, pastors, and priests.” He added: “By blaming porn, they put the problem external, when in fact, it is something internal which we need to address.”

The Republican platform amendment, by using words like “public health crisis,” “public menace” “predators” and “destroying the life,” seems designed to make us afraid, but it does nothing to actually make us safer.

If Republicans were truly interested in making us safer and healthier, they could focus on real public health crises like the rise of STIs; the imminent threat of antibiotic-resistant gonorrhea; the looming risk of the Zika virus; and, of course, the ever-present hazards of gun violence. But the GOP does not seem interested in solving real problems—it spearheaded the prohibition against research into gun violence that continues today, it has cut funding for the public health infrastructure to prevent and treat STIs, and it is working to cut Title X contraception funding despite the emergence of Zika, which can be sexually transmitted and causes birth defects that can only be prevented by preventing pregnancy.

This amendment is not about public health; it is about imposing conservative values on our sexual behavior, relationships, and gender expression. This is evident in other elements of the draft platform, which uphold that marriage is between a man and a women; ask the U.S. Supreme Court to overturn its ruling affirming the right to same-sex marriage; declare dangerous the Obama administration’s rule that schools allow transgender students to use the bathroom and locker room of their gender identity; and support conversion therapy, a highly criticized practice that attempts to change a person’s sexual orientation and has been deemed ineffective and harmful by the American Psychological Association.

Americans like porn. Happy, well-adjusted adults like porn. Republicans like porn. In 2015, there were 21.2 billion visits to the popular website PornHub. The site’s analytics suggest that visitors around the world spent a total of 4,392,486,580 hours watching the site’s adult entertainment. Remember, this is only one way that web users access internet porn—so it doesn’t capture all of the visits or hours spent on what may have trumped baseball as America’s favorite pastime.

As Rewire covered in February, porn is not a perfect art form for many reasons; it is not, however, an epidemic. And Concerned Women for America, Mary Frances Forrester, and the Republican subcommittee may not like how often Americans turn on their laptops and stick their hands down their pants, but that doesn’t make it a public health crisis.

Party platforms are often eclipsed by the rest of what happens at the convention, which will take place next week. Given the spectacle that a convention headlined by presumptive nominee (and seasoned reality television star) Donald Trump is bound to be, this amendment may not be discussed after next week. But that doesn’t mean that it is unimportant or will not have an effect on Republican lawmakers. Attempts to codify strict sexual mores are a dangerous part of our history—Anthony Comstock’s crusade against pornography ultimately extended to laws that made contraception illegal—that we cannot afford to repeat.