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You don't want to get a phone call from Sarah Gordon. Nor do you want to spot her on your front stoop. Or find a note from her taped to your front door indicating that she wants to discuss an "urgent, confidential health matter."
The mere fact that Gordon is attempting to communicate with you indicates bad news. You have tested positive for, or have likely been exposed to, a sexually transmitted disease: chlamydia, gonorrhea, syphilis, or HIV. Gordon is one of the seven disease-intervention specialists--popularly known as the "sex police"--employed by the Minnesota Department of Health. Under state law, if you test positive for any of these four sexually transmitted diseases (along with chancroid, an infectious venereal ulcer that is virtually nonexistent in Minnesota), your doctor must report it to the health department. A disease-intervention specialist like Gordon is then charged with contacting you, in an attempt to limit the spread of the disease. Syphilis, and in particular HIV, take precedence because they are potentially fatal.
No matter how sound the scientific basis for the program--or the health department's repeated assurances of confidentiality--people do not always take kindly to government bureaucrats showing up at their house to discuss the infection of their genitals. "STDs have, for lack of a better term, lots of baggage attached to them," concedes Steve Schletty, who oversees the program for the health department. "People can be reticent about talking. The thinking is, 'Here's this state employee on my front steps talking about the most intimate part of my life.'"
Disease-intervention specialists are charged not only with notifying citizens that they have tested positive for an STD, but also with quizzing them about their sex lives in order to determine who else might be at risk of infection. Gordon is well versed in the practice of asking people such uncomfortable questions. Prior to joining the health department, she did street outreach with prostitutes and homeless youth and presented safe-sex seminars in state prisons. She says that people often open up once it's clear that they have an opportunity to spare their sexual partners a lot of pain and medical bills. "By telling the health department partner names, you're not ratting them out," she tells clients. "You're helping them, and you're stopping the spread of disease." These sexual partners then receive a visit from the health department as well.
Things overheard at the STD clinic
Schletty recalls one case in which the only information he had on a sexual partner was that the man lived on the second floor of a four-story apartment building in Loring Park, and that the apartment overlooked the dumpster. Schletty eventually located what he believed was the correct apartment, but he was ultimately unsuccessful in trying to contact the tenant. "It was an interesting investigation, but it didn't have the best outcome, because my goal was to get to this guy before he had time to incubate and develop the disease," Schletty laments.
In other instances people flat out lie about their sex lives. Schletty recalls another man who insisted that the open sores on his penis were the result of a particularly nasty encounter with mosquitoes in the northern Michigan woods. It didn't take long for Schletty to discredit this novel medical theory. The guy turned out to have syphilis.
People often come up with responses that require a stiff upper lip on the part of health department employees. One client, when asked if her boyfriend knew that she had tested positive for a sexually transmitted disease, replied, "After I wrote it on his car in lipstick he did."
Like drug trends and prostitution hotspots, STD incidence follows wider social factors. This year the health department has seen an outbreak of syphilis among "men who have sex with men"--a category used because not all such men identify themselves as homosexual. In 2001 there were just five of these cases statewide. As of early October this year there had been 34 reported syphilis infections among gay men. In slightly more than half of those cases the men have also been HIV-positive.
The spike in syphilis infections was not unexpected: It follows similar outbreaks that have occurred recently in coastal cities with large gay communities. Miami, for example, has seen an annual 20-fold increase in syphilis cases among men who have sex with men over the past four years, according to the Centers for Disease Control. "Like fashion, what starts on the coasts moves to the heartland," says Schletty.
The increase in syphilis cases is particularly troubling because the disease is something of a trickster. In its early stages, people often do not exhibit any noticeable symptoms--yet they remain infectious. For this reason, a person may spread the disease unwittingly. This creates an increased level of urgency for the health department to let people know they may have been infected and refer them for testing and antibiotic treatment. One symptom of syphilis infection, the development of a lesion roughly the size of a pencil eraser, encourages the spread of HIV by providing an easy portal for the virus. What's more, in people who are already HIV-positive, syphilis can be difficult to diagnose. Because some of the symptoms are similar to the side effects of anti-viral medications, doctors may not perform the tests necessary to detect it.