Gonorrhea Always Rings Twice
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
Unfortunately people do not always keep the most detailed dossiers on their sexual companions. Sometimes people meet in online chat rooms and engage in anonymous sex. Other times, disease spreads through prostitutes or drunken trysts. Consequently, the sex police sometimes have little information to work with. A client may provide them with a first name, a physical description, and a neighborhood to track the person down. Or they may provide them with nothing but an online moniker that changes by the week. "This really is kind of a street-detective medical job," says Gordon.
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.
"Syphilis is known as the great imitator," says Tim Heymans, who primarily serves as a disease-intervention specialist in greater Minnesota. Heymans reports that he recently had a client with a full-body rash that his doctor had chalked up as a complication from his HIV medications. A few months later, however, the client popped up as a contact for someone who had tested positive for syphilis. "Most doctors never see a case of syphilis in their whole careers so they're not going to be ready for it," he says.
Heymans has encountered just about every sexual proclivity possible in his 13 years of notifying people that they've picked up an STD. He often deals with closeted gay men in rural Minnesota who are leading dual lives. "They go to Minneapolis for the sex, but they have a life out here that's either high-profile business or religious or community leader," he says. "You just never know somebody."
One summer he had an HIV-positive client who reported more than 50 sexual partners. Because HIV notifications must be done in person, and because of the urgency of letting people know that they may be infected, the investigation pretty much took over his life. "I'd get a call and have to drop everything and go."
Heymans has become somewhat hardened to the ugly task of informing a person that he may have contracted a terminal illness. He says that most people have a surprisingly stoic response to the news. In one case, Heymans drove several hours to inform a man that he had tested positive for HIV. Upon Heymans's arrival, however, the guy refused to accept the information, or even to confirm his identity. Only after some 15 minutes of improvised pleading was Heymans able to convince the client that it was in his best interest to be informed about his health status. Then when Heymans broke the bad news, the guy again shut down. "He was pretty freaked out and didn't want to talk anymore," he recalls. "It took him a couple of weeks to really settle down, and he eventually called me back to talk."
Showing up on people's doorstep and telling them that they've acquired a life-threatening disease can also be hazardous. Because poor people are disproportionately infected by STDs, the work necessitates spending time in some of the less welcoming corners of the Twin Cities. Heymans, however, says he's sometimes found working in rural Minnesota more disconcerting than the inner city. "I've been more afraid at times when I've been out on somebody's farm," he says. "There are no witnesses around, the next farm is maybe a half-mile away, my boss doesn't even know where I am. They just wouldn't find me for weeks."
Heymans had one client pull a knife on him, but the situation never escalated to violence. "He was visibly shaking, just really scared," he recalls. Another HIV-positive client challenged him to a fight after Heymans insisted that his girlfriend had to be notified of his diagnosis.
Ultimately nothing is scarier than dealing with parents. Because the notification process is strictly confidential, health-department workers go out of their way to keep parents in the dark. And most moms and dads aren't keen on strange adults showing up at the house asking to speak with their son or daughter. Gordon says the very first phone call she made after starting the job last November was to a minor. "I was very nervous, and of course I get the angry mom right off the bat who just curses me up and down because I won't say who I am or where I'm calling from," Gordon recalls.
Despite such obstacles, disease-intervention specialists take pride in their work. "Once in a while you hit a string of people who are just uncool, and you're wondering, 'Why am I doing this?" Heymans allows. "But mostly I just get really excited about disease investigation and intervention, about breaking the chain of infection."
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