Chapter 8: The Path of Least Resistance: Sailors, Sex Parties, and Gonorrhea Superbugs
Deep Throat
One Friday morning in June of 2018, I opened my work email to see a message from Yvonne Piper, a nurse practitioner who I work with at the STI clinic. The subject line read, “Sex party pharyngeal gonorrhea.” At that moment, I had two thoughts: 1) I love my job, and 2) my spam filter had given up trying to protect me from lewd content (in my line of work, it’s hopeless anyway). I continued reading Piper’s email, which contained a list of instructions preparing the clinicians for a potential influx of patients seeking testing for pharyngeal gonorrhea (GC):
“Recently we have had requests from cis [gender]women for pharyngeal GC testing. These women have self-identified as members of a sex party group on Facebook that has ~400 members. Some member of this group reportedly has gonorrhea. So far we have seen 4 people who are in this group; patients have let us know during the clinical visit that they are members of said group.
This is a pansexual play party group so expect you could have people of any gender coming in with this request. Make sure you take a good sexual history and only screen people who are performing fellatio—we are not offering this screening to people who report performing cunnilingus or analingus.”
Piper has nothing against cunnilingus or analingus, but those activities are not as efficient at getting gonorrhea to the back of the throat. The clinic had to prioritize who to test among the four hundred members of the sex party group, and fellatio can deposit gonorrhea right on the tonsils, where it can happily establish an infection.
Despite the size of the group, we weren’t expecting a horde of pansexuals with sore throats beating down our door. When Neisseria gonorrhoeae infects the throat, it rarely produces symptoms, enabling it to avoid detection on the part of its host. In most cases, the throat serves as a silent reservoir of infection; gonorrhea can only be detected there if someone thinks to look for it. Occasionally, it causes a sore throat and fever, mimicking a case of strep throat, but this is the exception, not the rule.
The silent infection is a clever survival strategy. To ensure propagation of the species, Neisseria gonorrhoeae must continue to be sexually transmitted to others. To do this, the bacteria needs to be hardy enough to withstand the environment of the throat, rectum, or genitals, and avoid being killed off by the host’s immune system. It needs to stay silent or cause symptoms mild enough not to arouse the host’s attention. If the host develops a raging case of tonsillitis or discharge, they are apt to throw antibiotics at it, dashing Neisseria gonorrhoeae’s chances of transmission.
Here’s another bacterial survival strategy: hide somewhere where it’s hard to kill you. Eradicating gonorrhea from the throat is more difficult than ridding it from other sites in the body, though the exact reasons for this are still unclear. Perhaps the immune response in the throat differs from that of the genitals or rectum, making it less likely that one will clear the infection at that site. It may be that antibiotics don’t reach high enough concentrations for long enough to successfully clear infection from the throat.
Once inside the throat, gonorrhea can sit for weeks or months hanging out with its cousins, other species of Neisseria that have names reminiscent of hip-hop artists: flava, subflava, sicca. These are permanent residents of the mouth and aren’t thought to cause any harm. Sometimes Neisseria meningitidis can also be present, a strain that can cause severe infections such as meningitis or also reside quietly without causing symptoms.
As they coexist together in the throat, the various Neisseria species exchange or donate pieces of DNA to each other, resulting in genes that are a combination or mosaic of the two different species. The bacteria with its new mosaic genes will multiply, be passed to someone’s genitals through oral sex, and then perhaps to someone else’s throat, where the process can occur again.
Over time, mutations to the chromosomes of Neisseria gonorrhoeae gradually morph the bacteria from its original state to one that is antibiotic resistant. It is a slow evolutionary process that happens over years, with multiple genetic changes required before antibiotic resistance develops.14 For that reason, the development of resistance to penicillin was almost forty years in the making.
At some point, however, gonorrhea found a shortcut to antibiotic resistance by having bacterial sex or conjugating with another type of bacteria in the throat, most likely a species of Haemophilus. Scientists think that Haemophilus transferred over a plasmid, a circular piece of DNA that can replicate independently from the rest of the bacterial chromosomes—and that is capable of carrying multiple antibiotic resistance genes. Never mind having to go through years of evolution. One act of conjugation involving a plasmid, and voilà—instant antibiotic resistance.15
With two mechanisms for developing antibiotic resistance, it’s no wonder that gonorrhea has managed to develop resistance to every antibiotic ever used to treat it. And now that we are down to one antibiotic (ceftriaxone) left to treat gonorrhea, what sounds like a bad B movie title is not so far from reality: Attack of the Sexually Transmitted Superbugs.
Indeed, mutant strains of pharyngeal and genital gonorrhea with resistance to ceftriaxone have reared their heads in the UK and other parts of Europe, Japan, and Australia from 2011 to the present day.16 So far, there have been scattered cases here and there, though none has taken off and spread widely through the population. How could this be?
If this were indeed a B movie, the mutant bacterium would grow ever more monstrous, then become unstable and self-destruct. This hasn’t really happened, but it is possible that these mutant strains of gonorrhea have reduced fitness, a concept related to a bacteria’s ability to replicate and survive. If mutant antibiotic resistant strains are less fit than their predecessors, they may die out before they can replicate and be transmitted, one saving grace to stave off a pandemic of super gonorrhea.
If throat infections play a key role in antibiotic resistance, perhaps preventing them could help public health’s gonorrhea response efforts. Using condoms for fellatio could likely help reduce transmission to the throat—that is, if anyone actually used them. I have asked patients whether they used condoms when performing fellatio, and people look at me like I am crazy. It simply isn’t done, at least not by the majority of the sexually active public. According to a study by Melissa Habel of the CDC, more than 75 percent of heterosexual adults reported giving or receiving oral sex, but only 6–7 percent used a condom the last time they did.17
Some clever Aussies have decided to try a different tack. Researcher Eric Chow has spent years trying to figure out why men who have sex with men have such high rates of gonorrhea. Along the way, he’s found gonorrhea in the saliva of men who also had gonorrhea in their throats, leading him to believe that saliva exchange during oral sex, kissing, or using saliva as lube during sex might be playing a role (which would also be true for women too).
With both the throat and saliva as potential culprits, Chow decided to throw some Listerine at the problem to see if it could help. And why not? Listerine was invented in 1879 as a surgical antiseptic, but later marketed as a floor cleaner, a vaginal douche, a cure for dandruff, and yes, even a treatment for gonorrhea (not sure exactly how it was applied).
In 2015, Chow conducted a small randomized controlled trial that included fifty-eight men with pharyngeal gonorrhea who had sex with men. He found that about half of men with gonorrhea who gargled with mouthwash for sixty seconds still had a positive throat culture, compared to 84 percent who just gargled with saline. Of note, this was serious gargling to the back of the throat, not a simple swish and spit.
Chow decided to go bigger and better with his idea, this time enrolling 530 Australian men who have sex with men in a study to see if mouthwash could actually prevent infections. The OMEGA Study (Oral Mouthwash used to Eradicate GonorrhoeA) involved daily gargling with two competing mouthwashes to see if either might reduce infections with pharyngeal gonorrhea.18 If a simple mouthwash could prevent gonorrhea infections of the throat, it could be a huge boon for gonorrhea control worldwide. Not to mention the pleasant minty breath that would pervade bars and nightclubs the world over.
While the final study results have yet to be released, in a 2019 interview for the Australian magazine Emen8, Chow warned people not to go crazy with mouthwash or stick it into other parts of their bodies. “I can definitely say you shouldn’t apply mouthwash to your penis or your anus.”19 May I go out on a limb and add: don’t put it in your vagina either.
While men who have sex with men are disproportionately affected by gonorrhea, the reasons for increased infections can be partly explained by a greater number of sex partners and higher rates of partner change. This would appear to support the popular wisdom that gonorrhea and other STIs are equal-opportunity infections driven by promiscuity. Unfortunately, this simply isn’t true. In the United States, gonorrhea infects with racist, classist, and misogynistic tendencies (think certain politicians as STIs). The root cause of these disparities isn’t found in the bedroom but instead in institutions where sex isn’t even allowed: our nation’s jails and prisons.
Chapter 2: Bushwhacked: Untangling Pubic Hair and STIs
Save the Crabs
According to the U.S. Fish and Wildlife Service, there are currently 1,456 endangered and threatened animal species, plus 29 additional candidates in line to make the list.7 One criterion for candidacy is that the species experiences “present or threatened destruction, modification, or curtailment of its habitat or range.”
For Pthirus pubis, the louse commonly referred to as “crabs,” it is clear that habitat destruction is rampant. In the United States and Europe, 70–80 percent of adults remove their pubic hair to some degree. The frequency and extent of grooming is greater among younger adults, and universities appear to be ground zero for depilation. In one study of grooming at public universities in Indiana and Georgia, 95 percent of students had removed their pubic hair at least once in the past month. There was a broad range of removal practices, ranging from light trimming to complete slash-and-burn. Researcher Debby Herbenick from Indiana University summed it up best: “Pubic hairstyles are diverse.”8
Hairlessness abounds regardless of age. In a study of over 7,500 U.S. adults aged eighteen to sixty-five, almost one in five qualified as an “extreme groomer,” someone who removes all their pubic hair more than eleven times per year. Another one in five were “high-frequency groomers” who perform some degree of removal either daily or weekly. Yes, there were even “extreme high-frequency groomers,” who remove all their pubic hair at least once a week—they made up less than 2 percent of the population.9 My guess is few people have that kind of time.
With all this pubic deforestation in mind, I searched for the pubic louse on the U.S. Fish and Wildlife Service website in vain. Despite clear evidence of habitat destruction, Pthirus pubis is not considered an endangered species.
You could have fooled me. I haven’t seen a good pubic louse in fifteen years. My last sighting occurred when I was a medical student rotating through the Los Angeles Free Clinic, which had a weekly afternoon clinic devoted to STIs. I saw a patient who hoped he had an STI because otherwise he worried he might be going crazy. For more than a week he’d had uncontrollable itching in his groin, yet he couldn’t see any bites or a rash that would explain his symptoms. He’d bathed in hot water, slathered hydrocortisone all over his skin. Yet he just kept itching. It was getting a bit embarrassing to scratch himself so frequently, particularly in public.
To begin sleuthing, I lowered my head to get a bird’s-eye view of his genitals. My eyes focused first on his penis, which looked fine. Then by relaxing my gaze, his penis faded into the background and his pubic hair came into focus. That was when I saw them. Dozens of tiny lice, clinging to his hair just as happy as you please. With his permission, I pulled out one of the hairs, laid it on a glass slide, and made my way to the laboratory.
Under the microscope, I could see the louse’s squat, segmented body and claws, its latest blood meal visible through its translucent skeleton. It was a triumphant moment. When I told the patient his diagnosis, he was relieved that he wasn’t crazy, and he thought I was a genius for figuring it out. That he had an STI barely registered.
I wasn’t sure if my drought of crab sightings was unique, so I took an informal poll of the nurse practitioners at my STI clinic. Chuck, our most seasoned practitioner, hadn’t seen them in seven years. Liz, one of our youngest clinicians, had never seen them at our clinic. Then Tae-Wol piped in that he’d seen several cases in the past few months. A recent arrival to the world of STIs, he’d previously worked in homeless and addiction medicine. I thought that was the connection; perhaps his patients still had their pubic hair. No, he assured me. The patients with pubic lice just seemed to gravitate toward him.
He also brought up an important observation. One of the patients he had seen was a pubic groomer, so there was scant hair in the man’s groin. Tae-Wol had witnessed lice furiously scrambling, trying to cling to this patient’s stubbly pubic growth. Then he had observed crabs in the hair over the patient’s stomach and chest.
I was skeptical. Body lice, head lice, and pubic lice are different species, and each has its preferred habitat. “Those weren’t body lice?” I asked.
Tae-Wol wagged his finger at me, shaking his head. “I know my lice,” he insisted. These crabs had been displaced from their genital home; they had migrated along a trail of hair from the pubis to the abdomen. Now they were refugees in a strange land.
A quick search of the medical literature turned up more evidence of Tae-Wol’s observation. In 2017, there was a reported outbreak of pubic lice among eight women in a Japanese nursing home. Six had pubic lice in their scalp hair only, while the other two women had pubic lice in their pubic hair only.10 An infested hairbrush shared between patients was partly to blame. How lice got from someone’s pubic hair to the hairbrush or from someone’s pubic hair to another’s scalp hair remains a mystery. I don’t like to imagine the potential scenarios.
It remains to be seen whether pubic lice will successfully adapt to scant pubic hair or the finer, softer hair of the body and head. For decades, ecologists have demonstrated that species that can’t cope with reduced area and increased isolation from habitat fragmentation eventually become extinct.11 And the warning signs are there. At STI clinics in the UK, Janet Wilson and Nicola Armstrong described a 60 percent decline in the proportion of patients with pubic lice from 1997 to 2003.12 Then Shamik Dholakia from Milton Keynes General Hospital in the UK observed the incidence of pubic lice fell more than 90 percent from 2003 to 2013 (from 1.8 percent to 0.07 percent of patient visits), while the incidence of pubic grooming increased from 33 percent to 87 percent.13
Coincidence? I think not.
After reading Wilson and Armstrong’s publication, “Did the ‘Brazilian’ Kill the Pubic Louse?” the Natural History Museum Rotterdam’s curator Kees Moeliker realized that there were no Pthirus pubis specimens in its collection of over three hundred thousand different species. He put out an appeal in October 2007 through the Associated Press, asking for a generous soul to donate a pubic louse for its collection.14 By 2013, Moeliker still had no takers. Comedian Jessica Williams learned of his quest and accompanied him around New York to ask strangers for pubic lice in her investigative piece for The Daily Show, “Beasts of the Southern Wild.” In the piece, she gathered other friends of the pubic louse together to highlight its plight, including director John Waters, singer Aimee Mann, and my colleague Jonathan Zenilman.
Zenilman is a professor in infectious diseases at Johns Hopkins University in Baltimore, one of the few remaining pubic lice strongholds in the United States. He still sees pubic lice regularly, every few months or so. He agrees they are not as abundant as they used to be, but feels they are not anywhere near extinction—at least not in Baltimore. I called him up to share my concern that an entire generation of millennial nurses and doctors might never know the joy of diagnosing crabs. Did he think we should mobilize our colleagues to start a rescue campaign?
Not to worry, he reassured me. “Our crowd [the STI researchers] is always trying to put itself out of business by eliminating STIs. Between climate change [creating a favorable climate for lice] and people’s sexual practices, these sexually transmitted creatures are going to be with us for a very long time.”
He felt global travel would also help. Pubic lice were all over the earth, in many locales where people still sported a healthy amount of pubic hair. In the book Infections of Leisure, Zenilman noted that travel afforded one with a sense of adventure, periods of loneliness, and exploration away from one’s home environment—the perfect setup for sex with someone new.15Global travel continued to rise through 2018 and 2019, and hopefully some good travel sex right along with it.16
Although current grooming trends may continue among adults in the United States and Europe, human hair grows back quickly (unlike Brazilian rain forests). Extreme high-frequency grooming is still rare. There is likely enough hair on enough people to keep the crab louse going for a while.
Like rising and falling hemlines, there’s even a chance that pubic hair will come back into fashion. In June 2017, model Amber Rose created buzz when she posted a nude photo of herself with pubic hair on Instagram, captioned “#bringbackthebush.” The next month, Mark Hay reported in Vice that the bush was reappearing in porn. Even if a full bush doesn’t come back, Pthirus pubis has been with us humans for at least three million years.17 I’m sure it has weathered worse storms than this. If the situation becomes truly dire, I found a T-shirt for order online that reads, save the crab louse. stop pubic deforestation.
If pubic lice actually become extinct, there’s still hope of glimpsing them for yourself. Kees Moeliker wrote me that he finally received several Pthirus pubis specimens after his stint on The Daily Show. They are now safely preserved in his museum in Rotterdam, should anyone need to pay their last respects.
While I don’t think we truly need to fear the extinction of the pubic louse, I wonder if we humans are experiencing other harms from widespread pubic deforestation. Perhaps pubic hair actually serves a purpose other than as a habitat for lice. What if it is protecting us in some way that we don’t yet appreciate? If so, then what are the unintended consequences of cutting it down?