About 12,000 women in the United States get cervical cancer each year. While this number has not gone up, researchers have recalculated the rate of cervical cancer in the country and found that it's higher than we thought, with some groups at much higher risk than previously believed.
Researchers released new data this week suggesting that the rate of cervical cancer in U.S. women of all ages had been underestimated. Around 12,000 women in this country get the disease each year and 4,000 die from it. This has not changed, but the rate—which is expressed by saying how many out of 100,000 women will get the disease each year—has gone up by 55 percent in these new calculations because researchers stopped including women who’ve had hysterectomies.
A hysterectomy, or surgery to remove the uterus, also involves removing a woman’s cervix. Though the number of hysterectomies performed in the United States has been declining recently, it is still estimated that more than 500,000 women get the surgery each year. These women had previously been included in the calculations despite the fact that they were no longer at risk for cervical cancer. Researchers believe the new numbers, which show that the same number of cases actually occurs among fewer women, provide a more accurate assessment of women’s cervical cancer risk at various ages.
Previous studies had estimated that the U.S. cervical cancer rate was about 12 cases per 100,000 women, that the highest rates were in women between ages 40 and 44, and that the incidence leveled off as women got older.
The new calculations show that there are 18.6 cases per 100,000 women of all ages and that the highest rates are actually in women 65 to 69. In fact, the rates for women in this age group jumped 84 percent (from 14.8 to 24.7 per 100,000 women) when women who’ve had hysterectomies were removed from the equation.
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While this makes sense because the likelihood of hysterectomies increases with age, it suggests that the medical community may have been underestimating the risk of cervical cancer for older women who still have a uterus and a cervix. The other large jump was in the rate for African-American women, which went from 23.5 to 53 cases per 100,000 women, an increase of 126 percent. Again, the reason for this significant change is that African-American women have higher rates of hysterectomies overall.
Cervical cancer is a slow-growing cancer that can be treated early (even in precancerous stages) if detected. Screening tests for this cancer include the Pap test, which scrapes cells off the cervix. Cells are then looked at under a microscope to determine cancerous or precancerous changes. A new generation of testing also uses cells scraped from the cervix to look for high risks strains of the human papillomavirus (HPV), two of which—strains 16 and 18—are known to cause 70 percent of cervical cancers.
As of now, the American Congress of Obstetricians and Gynecologists (ACOG) recommends that women between the ages of 21 and 29 have a Pap test every three years and that women ages 30 to 65 have a Pap test plus HPV testing every five years. According to ACOG, women 65 and over do not need to be tested if previous testing was negative. These recommendations may change as a result of an FDA decision this month that allows health-care providers to use the HPV test instead of the Pap test, or along with it, for women of all ages. There’s also a chance that they may change because of the recent study, which suggests women, especially those over 65, are at more risk than experts had thought.
Anne Rositch, an assistant professor of epidemiology and public health at the University of Maryland School of Medicine and one of the authors of the study, said in a statement, “It will be important to consider these findings when reevaluating risk and screening guidelines for cervical cancer in older women and the appropriate age to stop screening.” She added that further research was necessary to determine “whether the continued increase in cervical cancer rates with age and the higher rates in African-American women represent a failure in our screening programs or a failure of the women to be screened so that appropriate interventions can be applied.”
While more research is being done and medical organizations like ACOG reevaluate the recommendations, women should work with their doctors to assess their own risk and develop a screening plan. Dr. Tara Shirazian, a gynecologist at Mt. Sinai Hospital in New York City, told CBS News, “I think risk factor-based assessment needs to be done for every patient. So every woman that comes to see me in the office we do an individual risk assessment. Has she ever had an abnormal pap smear, does she have HPV? Has she ever had HPV? Has she ever had any surgery to the cervix from HPV-related disease? Those sorts of things should go into continued monitoring of the individual woman for cervical cancer.”
Of course, the most important thing is that women continue to seek gynecological care even as they age. Younger women should also consider getting the HPV vaccine, which is available to those ages 9 to 26 and has been shown to dramatically reduce the risk of contracting the HPV strains most likely to lead to cervical cancer.
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.
Dominick, a disabled transgender man, started making the arrangements for a hysterectomy at age 30. The experience turned out to be a living nightmare—and not just because being disabled had previously presented obstacles to medical care, like being unable to access his gynecologist’s office.
“The doctor,” he says, “sent me home while internally bleeding after the surgery because he needed more beds. He ignored my concerns and dismissed my symptoms as overblown.” He says he almost died when he started hemorrhaging at home.
The horrors of that experience led Dominick to shy away from follow-up care and had profound psychological consequences. “I was afraid to leave my house, for fear I’d start bleeding out. I remember being on a bus to school, completely alone, and having a complete meltdown. I called my girlfriend and was crying and shaking and begging her to come get me.”
While he survived the experience, the trauma lingers to this day—and he’s not alone. For many trans men, dismissive treatment in the gynecologist’s office is part of a larger framework of harmful health-care practices that include verbal and physical abuse and denial of care. Thanks to the finalization of an Affordable Care Act (ACA) rule banning discrimination on the basis of gender, trans patients now stand to access care more easily, but enacting policies against discrimination isn’t quite the same as actually eliminating it. Trans people often face obstacles to care in health-care fields, unless they’re lucky enough to live in a region with a well-organized and structured clinic. Doctors who are ignorant about trans needs, like the imperative of surgical transition for some transgender people, can become dangerous roadblocks. And self-advocacy—including standing up for one’s immediate needs or asking for additional support in cases like Dominick’s—can be exhausting or impossible when continuously faced with such experiences.
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Reproductive health care in particular cuts to the heart of bodily autonomy, something trans people are often already denied in other settings. Yet trans men are frequently left out of the discussion when it comes to accessing services, even as the Women’s Health Network and other organizations, like the American Congress of Obstetricians and Gynecologists (ACOG), argue that the health needs of people who are assigned female at birth, no matter their gender, are indeed matters for reproductive rights conversations.
When it comes to seeking medical care in general, trans people say they often face ignorance or outright prejudice from medical professionals. A 2011 study conducted by the National Center for Transgender Equality and the National Gay and Lesbian Task Force found that 20 percent of survey respondents were denied health care due to their transgender or gender-nonconforming identity—and people of color experienced even more profound disparities. Twenty-eight percent of all respondents said they had been harassed in physicians’ offices, and 2 percent experienced physical violence.
Chillingly, when care providers discovered that their patients were transgender, the incidence of discriminatory attitudes increased. Many didn’t understand the needs of the transgender community, forcing half of the respondents to provide basic education about managing transgender patients. While proactive self-advocacy—being educated about your own health, self-assured at the doctor’s office, and ready to speak up for yourself—can help everyone achieve better health-care outcomes, this goes far beyond advocacy. In a medical culture where people may have difficulty obtaining providers, trans patients can be forced to repeatedly discuss sensitive medical information that can trigger dysphoria and frustration. And gender dysphoria is fatal if untreated: A staggering 41 percent of the trans community has attempted suicide.
While all aspects of medical care are important, reproductive health care sits at the axis of many important oppressions: It determines whether people are able to have families, whether they receive treatment after rape and sexual assault, if potentially serious sexually transmitted infections (STIs) are treated in a timely fashion, or if they can obtain compassionate and appropriate abortion care. And here, too, trans people have reported difficulty when it comes to requesting and receiving breast and cervical cancer screenings, STI testing and treatment, fertility care, contraception, abortion and pregnancy care, and other reproductive health needs. When such care is provided, it may come with detrimental comments and practices like misgendering patients or making assumptions about their personal lives.
But whether people are transgender men, along the nonbinary spectrum, agender, or along other axes of gender and experience, if they aren’t cisgender women, they say their reproductive health needs are often dangerously ignored.
“My first gyno, who was an older woman with all kinds of vocalized homophobic, transphobic, racist, and HIV-ignorant ideas,” says K., “left me so uncomfortable I wouldn’t let anyone touch me between my legs with their hands for a good ten years!” K., who is nonbinary, had a traumatic experience when seeking abortion care, and, like Dominick, wasn’t provided with counseling on the subject of egg storage before starting hormone therapy. “I personally never want to be pregnant again,” K. says, but the very option of freezing eggs and using a surrogate in the future was denied.
And this has real consequences: Trauma in reproductive health services, like that Dominick experienced, can drive transgender people into fearing the health-care system as a whole. Between discrimination and the fear that keeps people out of doctors’ offices, trans people are less likely to get preventive care—like HIV counseling and screening—and more likely to develop complications from delayed care. That includes vitally needed reproductive health services.
Discriminatory practices in gynecological care take place within the framework of another problem for trans people: Even with the ACA’s theoretical increased access to health care, substantial barriers to health-care access remain. Transgender people—particularly women and people of color, but also men to a lesser extent—are four times more likely to live in poverty, thus driving a disproportionate use of Medicaid coverage. As Rewire has reported, 16 states explicitly deny transition-related services under Medicaid coverage. Although the ACA explicitly bans discrimination on the basis of sex and gender, with additional protections for gender-nonconforming individuals now that the Department of Health and Human Services (HHS) has finalized its ruling on Section 1557, that doesn’t always work out in practice. Coverage of transition-related treatment, including hormones and surgery, may be denied as “elective” or “aesthetic” under insurance exclusions. For example, a hysterectomy may be deemed “not medically necessary.” Trans people can be instead forced to sue for their care, as in 2014, when Illinois woman Naya Taylor demanded access to hormones. This is especially true in cases where people have successfully changed the gender markers on their identifications, thereby creating a situation where Medicaid may deny coverage for activities like Pap tests for men or prostate cancer screening for women.
“I’ve got many stories about things that have gone wrong in my interactions with medical professionals,” remarks Everett Maroon, a transgender man who lives in the Pacific Northwest with his wife and family. “I’ve gotten inappropriate medical advice, incorrect therapies, seen medical and cultural incompetence, dealt with shitty care, not been provided options I should have gotten.” His issues are the health-care system’s issues, and they are a subject that should be of critical concern to everyone fighting for reproductive rights.
Fortunately, that’s growing to be the case more and more. As OB-GYN Cheryl Chastine wrote for Rewire last year, “How can providers or activists dare to presume that every patient we can’t ‘read’ as trans is cis?,” she said, adding “When those in the reproductive justice movement prioritize trans inclusivity, more trans individuals feel comfortable publicly identifying as such.”
Her commentary was just one example of the growing chorus of support from the reproductive rights and justice community as people come to understand that reproductive health needs are complex, and some populations have historically been left out of the equation.
Combating that oversight includes taking on challenges like providing competency training to health-care providers in medical school and beyond—including the recommendations ACOG is putting forward. Trans-competent health training should allow clinicians to put their patients at ease. At minimum, it should include discussions about gender identity and presentation, how to handle medical issues that may trigger dysphoria, how hormones might affect other prescriptions and the patient’s general health, and why trans patients may feel distrustful and uncertain around health-care providers.
It also includes passing comprehensive legislation to affirm that transition care and related medical treatments are covered by private insurance, Medicaid, and Medicare. And it includes robust third-party investigation—regulated by the HHS, whose Office of Civil Rights is responsible for enforcing the ACA’s nondiscrimination protections—of grievance complaints filed by trans patients, such as those made directly at clinics and hospitals in addition to those filed with state licensing boards.
It’s time to take trans health care seriously. Doing so will create a world of radical inclusion where people can feel safe seeking health care wherever they go.