Sexually Transmitted Diseases:
Gonorrhea in the United States, 1981‐1996: Demographic and Geographic Trends
FOX, KIMBERLEY K. MD, MPH*; WHITTINGTON, WILLIAM L. BA*,‡; LEVINE, WILLIAM C. MD, MSc*; MORAN, JOHN S. MD, MPH*; ZAIDI, AKBAR A. MS†; NAKASHIMA, ALLYN K. MD*
*From the Epidemiology and Surveillance Branch and †Statistics and Data Management Branch, Division of STD Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; and the ‡Center for AIDS and STD, University of Washington, Seattle, Washington
The authors gratefully acknowledge the data management and programming assistance of Alesia Jester Harvey and helpful comments provided by Melinda Flock.
Reprint requests: Dr. Kimberley K. Fox, HIV/STD Prevention and Care Section, N.C. DHHS, P.O. Box 29601, Raleigh, NC 27626‐0601.
Received February 6, 1998, revised April 29, 1998, and accepted May 5, 1998.
Objective:: To describe demographic and geographic trends in gonorrhea incidence in the United States from 1981 through 1996.
Study Design:: We analyzed aggregate gonorrhea cases reported to the Centers for Disease Control and Prevention by the 50 states, District of Columbia, and 63 large cities. Annual incidence rates (cases/100,000 persons) were calculated.
Results:: Between 1981 and 1996, the incidence of reported gonorrhea decreased 71.3%, from 431.5 to 124.0 cases/100,000. However, rates among blacks were 35 times higher than rates among whites in 1996 (684.6 versus 19.4) compared with 11 times higher in 1981 (1,894.3 versus 164.3). Among women of all races, 15 to 19 year olds had the highest rates (716.6 in 1996), whereas among men, 20 to 24 year olds had the highest rates (512.9 in 1996). Southern states had higher rates than other regions.
Conclusions:: Large segments of the population, including adolescents, young adults, and blacks, continue to have high rates of gonococcal infection; prevention programs and health care providers should address the needs of these groups.
SINCE THE 1940s, gonorrhea has been one of the most frequently reported communicable diseases in the United States.1 Gonorrhea rates declined in the late 1940s and 1950s after the advent of penicillin therapy and during a period of relative social stability. However, rates began to increase in the late 1950s and increased markedly from 1966 to 1975, a period when sexual behavior patterns were changing dramatically.2,3 In response to the rising incidence, public health agencies and health care providers initiated gonorrhea control efforts based on widespread screening of asymptomatic women using newly developed selective culture media. Increased numbers of cases from 1972 to 1975 and falling rates since 1975 have been attributed in part to these efforts, which led to treatment of asymptomatic infected persons and their sexual partners, interrupting transmission of the infection.2,4
Despite these successes, gonorrhea rates in the United States remain the highest of any industrialized country.5 High gonorrhea rates adversely affect the nation's health through two mechanisms. First, gonorrhea is a major cause of pelvic inflammatory disease and subsequent infertility and ectopic pregnancy.6 Second, recent data suggest gonorrhea may facilitate human immunodeficiency virus (HIV) transmission.7,8
To describe the current epidemiology of gonorrhea, we examined trends in the demographic and geographic distribution of reported gonorrhea in the United States from 1981 through 1995.
We analyzed gonorrhea surveillance data reported to the Centers for Disease Control and Prevention (CDC) from 1981 through 1996. Each quarter, the 50 states, the District of Columbia, and 63 large (population more than 200,000 in 1980) cities reported aggregate cases by gender and source of report (private or public). Definitions of public sources varied by reporting area from sexually transmitted disease (STD) clinics to all publicly funded clinics. Each year, the 50 states, the District of Columbia, and six major cities reported aggregate cases by age group, gender, race/ethnicity, and source of report. Quarterly reports identified more cases than annual reports except in 1992 and 1993; the numbers of cases reported in the two data sources were within 2% of each other except in 1981 (6.4%), 1983 (19.6%), and 1984 (16.6%). Quarterly reports were used for analyses not involving age or race/ethnicity because of the large number of cases missing from annual reports 1981 through 1985.
Race/ethnicity categories were white (not of Hispanic origin), black (not of Hispanic origin), Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native. Race/ethnicity data were incomplete for some states, especially during the early 1980s. For race/ethnicity analyses, cases with unknown race were excluded and states reporting race/ethnicity for less than 50% of cases in any year were excluded for that year.* The proportion of annual cases excluded from race/ethnicity analyses ranged from 16.3% in 1992 to 25.6% in 1984. For age analyses, cases with unreported age or incompatible age categories and states reporting age for less than 50% of cases in any year were excluded for that year.† The proportion of annual cases excluded from age analyses ranged from 2.0% in 1982 to 9.9% in 1993. Exclusion, rather than prorating according to the race/ethnicity, distribution in cases with complete data was used because the pattern of missing data in some years and states with many incomplete reports suggested a bias in the race/ethnicities reported. Exclusion was similarly chosen for handling missing age data.‡
Annual incidence rates (cases/100,000 persons) were calculated using published Bureau of the Census population estimates and intercensus estimates as previously described.1 When data from states that did not adequately report age or race were excluded, the state population estimates were also excluded from the denominator of rate calculations. Gender‐, age‐, and state‐specific rates were not calculated for Hispanics, Asian/Pacific Islanders, and Native American/Alaskan Natives because of small numbers of cases and intermittent reporting of these racial/ethnic categories.
Geographic analyses were performed by state and region.‡
The annual number of reported gonorrhea cases in the United States decreased 67.1%, from 990,864 cases in 1981 to 325,883 cases in 1996. Gonorrhea incidence declined 71.3% during the period, from 431.5 to 124.0 cases per 100,000 population. This rate declined gradually from 1981 to 1984, with average annual rate decreases of 4.9%, increased 2.5% from 1984 to 1985, then decreased again through 1996 with average annual rate decreases of 9.6%.
Men comprised 51% of gonorrhea cases and women comprised 49% of cases in 1996. Whites accounted for 15% of cases in 1996, blacks for 79%, Hispanics for 5%, Asian/Pacific Islanders for 0.4%, and Native Americans for 0.7%. The South reported 54% of all cases in 1996; adolescents aged 15 to 19 years accounted for 31% of 1996 cases.
Trends in gonorrhea rates varied by race, gender, and age group (Figure 1). Rates in white men and women were consistently lower than rates in black men and women. Rates in white men declined rapidly to low levels (14.8 cases/100,000 in 1996), whereas rates in white women declined more slowly and were higher than rates in white men after 1986 (23.7 cases/100,000 in 1996). Among whites, 20‐ to 24‐year‐old men consistently had higher rates (51.0 cases/100,000 in 1996) than men of any other age group. In contrast, 15‐ to 19‐year‐old white women had higher rates (160.6 cases/100,000 in 1996) than white women of any other age group after 1984.
In 1981, the gonorrhea rate among blacks was 11 times higher than the rate among whites (1,894.3 versus 164.3 cases/100,000); by 1996, the rate among blacks had fallen but not as dramatically as among whites, causing the black‐to‐white incidence ratio to increase to 35 (684.4 versus 19.4 cases/100,000). Black men had rates higher than any other race or gender group throughout the period, with little decline before 1990 (811.0 cases/100,000 in 1996); rates in black women were somewhat lower (570.8 cases/100,000 in 1996) and generally paralleled those in black men (Figure 1). As with whites, 20‐ to 24‐year‐old black men had higher rates (3,160.8 cases/100,000 in 1996) than any other age group, and 15‐ to 19‐year‐old black women had higher rates (2,888.4 cases/100,000 in 1996) than any other age group after 1984. Rates among black and white 15 to 19 year olds decreased by 47.5% and 76.4%, respectively, from 1981 to 1996, whereas rates among blacks and whites aged 20 to 24 years decreased by 61.3% and 88.1%, respectively.
Gonorrhea rates in 10 to 14 year olds of all races increased from 43.9 cases/100,000 in 1981 to 66.3 cases/100,000 in 1986 and then decreased to 32.0 cases/100,000 in 1996. Rates in 10 to 14 year olds peaked among white boys in 1981 (4.8 cases/100,000), white girls in 1986 (30.7 cases/100,000), black boys in 1989 (182.8 cases/100,000), and black girls in 1989 (490.6 cases/100,000).
Gonorrhea rates decreased steadily among Native Americans (71.4 cases/100,000 in 1996) and Hispanics (60.2 cases/100,000 in 1996), whereas Asians had very low rates throughout the period (13.0 cases/100,000 in 1996) (Figure 2).
Gonorrhea rates decreased in all states but remained highest in the South throughout the period (Figure 3). Among whites, rates were highest in the West and South and lowest in the Northeast in 1981, but by 1996 all regional rates were low (range, 10.1 cases/100,000 in the Northeast to 27.3 cases/100,000 in the South). Among blacks, rates were highest in the West and South during the first half of the period and in the Midwest and South during the second half of the period. Rates among blacks in 1996 were consistently high but with substantial regional differences: 812.3 cases/100,000 in the Midwest and 707.6 cases/100,000 in the South compared with 543.8 cases/100,000 in the Northeast and 357.3 cases/100,000 in the West.
Gonorrhea rates in the 63 large cities for which separate rates are available beginning in 1984 paralleled trends in the rest of the country, with decreases of 69.4% and 63.2% for these cities and remaining areas, respectively, from 1984 to 1996. However, not all cities experienced dramatic decreases in gonorrhea, and rates remained higher than 0.5% (500/100,000) in 12 cities in 1996 (Table 1).
Source of Report
An increasing proportion of reports came from private sources during this period (24.1% in 1981 to 48.1% in 1996). Among whites, cases from private sources comprised 28.1% of cases in 1981 and 53.0% of cases in 1996. There was substantial regional variation. In 1996, 81.0% of cases among whites in the Northeast were from private sources, 66.2% in the Midwest, 55.4% in the West, and 42.7% in the South. More cases among white women were from private sources (57.5% in 1996; regional range, 45.4‐87.7%) than among white men (45.6% in 1996; regional range, 37.9‐69.1%).
Trends were similar, although at lower levels, among blacks, with 17.0% of cases in 1981 and 35.2% in 1996 from private sources. In 1996, 61.5% of cases among blacks in the Northeast were reported by private sources, 42.7% in the West, 40.7% in the Midwest, and 30.4% in the South. Only 23.5% of cases in black males (regional range, 20.3‐43.3%) and 50.2% of cases in black females (regional range, 43.8‐81.8%) were from private sources in 1996.
The proportion of cases reported by private sources was similar in adolescents (aged 15 to 19 years) compared with older persons during the entire period (data not shown).
Ratio of Cases in Men to Cases in Women
The male‐to‐female ratio of gonorrhea cases in the United States decreased from 1.5 in 1981 to 1.0 in 1996. Among whites, the male‐to‐female ratio decreased from 1.5 to 0.6, whereas among blacks the ratio changed only from 1.5 to 1.3 during the same period. Male‐to‐female ratios were highest in the West in all years (1996: 1.2 among whites, 1.4 among blacks) compared with other regions (1996: 0.4‐0.6 among whites, 1.1‐1.3 among blacks).
From 1981 through 1996, gonorrhea rates declined in all states and among all age and race groups. This decline may in part reflect the continued impact of screening programs begun in the early 1970s2,4 and the continued availability of effective single‐dose therapy. Screening programs identify asymptomatic infections‐especially among women‐that are important in the persistence of gonorrhea in the community.9,10 Effective single‐dose therapy has long been a main‐stay of gonorrhea control because it avoids problems with treatment adherence.3 Changes in sexual behavior in response to the HIV epidemic may also be partly responsible for these trends. Reports of increased condom use and reduced risky sexual practices among men who have sex with men11,12 accompanied decreases in rectal gonorrhea in the mid‐1980s in several cities.13–15 The decline in gonorrhea among men and the decreased male‐to‐female case ratio among whites seen in our data may be related to these behavioral changes in men who have sex with men. Recent data suggest, however, that gonorrhea may again be increasing among this group.16
Evidence for sexual behavior change among heterosexuals in response to the threat of HIV is more limited,17 but increasing condom use, especially among those using hormonal methods of contraception, has been documented in several studies in the 1990s.18,19 Another factor that may have contributed to the overall decline in gonorrhea rates is a shift in the age structure of the U.S. population; the proportion of the population that fell into the highest risk age groups (15‐19 years and 20‐24 years) decreased steadily from 18.5% in 1981 to 13.6% in 1996 (data not shown).
Decreasing gonorrhea rates in the 1980s and 1990s were accompanied by reported increases in other sexually transmitted diseases. Two syphilis epidemics during this period led to the highest rates of this disease since 1949; the first was among gay and bisexual men from the late 1970s to the early 1980s, and the second, which peaked in 1990, involved primarily blacks and was associated with crack cocaine use.20 Gonorrhea rates continued to decline, although slowly, in the same population groups that experienced rapid increases in syphilis in the late 1980s; possible explanations for this divergence of trends include differences in the sexual behaviors associated with efficient transmission of these diseases, health care‐seeking behavior among infected persons, the widespread screening for asymptomatic infection among women,21,22 and dramatic differences in the endemic levels of these diseases. Reported chlamydial infection also increased in the 1980s; however, trends in chlamydial infection during that time reflect increasing recognition of the disease and availability of diagnostic tests.1
Gonorrhea rates have historically been higher in the South than in other parts of the United States. Despite rate decreases in all regions, regional differences in gonorrhea rates persisted throughout this 15‐year period. Populations of southern states are marked by high prevalences of several characteristics associated with high STD rates: poverty, income inequality, low social status of women, low educational attainment, and limited accessibility and utilization of health care services.23
The South also has a greater proportion of minorities than other regions of the United States. Although overall gonorrhea rates declined throughout the 1980s, decreases in rates among blacks were substantial only after 1990, and rates remained much higher than among whites. Reporting bias may partially account for higher rates in blacks. Public sources, which identified two‐thirds or more cases each year in blacks but only one‐quarter to one‐half of cases in whites, report more completely than private sources.24–26 Adjusting for these differences in reporting rates would nonetheless leave large, and increasing, racial disparities in gonorrhea morbidity.
Reasons for these racial disparities in gonorrhea and other STDs have been explored in recent reviews.27,28 The relationship between STD rates and race is complicated by several factors for which race may be a proxy; these factors include socioeconomic class, neighborhood, sexual partner choices, and sexual practices.27–30 Health services availability is affected by socioeconomic class and neighborhood, and health services utilization may differ by race.3,27,28 In addition, two population‐level factors that may increase the incidence of certain STDs‐youthful age composition and ratio of women to men greater than one‐are seen to a greater extent among blacks and other minorities than among white Americans.31
Data on differences in sexual behaviors between whites and blacks are limited. A recent national survey showed that although blacks were more likely to have had more than one sexual partner in the last year, they were also more likely to have used condoms at the last sexual contact and more likely to have changed sexual behaviors in response to the acquired immunodeficiency syndrome epidemic.32 In that survey, black race was an independent risk marker for STD, after controlling for numbers of partners and other sexual behaviors.33 Smaller studies of women attending STD and family planning clinics showed that black women had sexual behaviors less risky than those of white women yet had equal or higher STD rates.29,30 In summary, intertwining social and economic factors, along with geographic clustering and sexual partner choices along both socioeconomic and racial lines, may help explain persistent racial differentials in STD rates despite similarities in other measures of risk.23
Gonorrhea rates among black and white adolescent women declined less than rates in any other demographic group from 1981 through 1996. Adolescents are more susceptible than adults to certain STDs for both physiologic and behavioral reasons and may also have a higher risk of developing complications of gonorrhea such as pelvic inflammatory disease.34 Continued high gonorrhea rates among adolescents are consistent with increased proportions of teenagers engaging in premarital sex,35 low rates of condom use, inadequate knowledge about STD prevention,34 and delays in seeking treatment for STDs because of fear of parental notification.36
Aral et al37 suggested that the denominator for rates of STDs in adolescents should be the number of adolescents who are sexually experienced, because this would more accurately reflect the disease risk faced by adolescents engaging in sex. For example, only 53% of high school students in 1995 had ever had sex35; dividing reported gonorrhea in 15 to 19 year olds by the number of sexually experienced adolescents yields a rate among those at risk twice as high as the rate calculated using standard population denominators (1,024.0 versus 542.7 cases/100,000).
The relative increase in cases reported from private sources could be explained in several ways. First, diagnosis and reporting of gonorrhea in private settings may have improved. Nonculture tests, that often allow testing for Chlamydia trachomatis and Neisseria gonorrheae with a single specimen, have simplified the diagnosis of gonorrhea and are increasingly used in the private sector; many central laboratories that process such tests report positive results directly to public health authorities (CDC, unpublished data), so reporting rates are high. Campaigns to increase awareness of reporting responsibilities and to facilitate reporting by private physicians (CDC, unpublished data) may also have increased reporting rates for private settings. Second, persons at risk for gonorrhea may be increasingly using private health services for STD care. As managed care organizations have extended their reach to poor and minority populations‐traditional users of public clinics‐through contracts with Medicaid programs,38 limited funds have left many public clinics with poorly maintained facilities, inadequately trained staff, outdated laboratory equipment, and limited hours of service.39,40
Interpretation of the trend in the male‐to‐female case ratio is complex. A high ratio may reflect failure to detect asymptomatic disease in women, underreporting of disease in women more than in men, large numbers of men infected by small numbers of women (such as commercial sex workers), or disease in men who have sex with men. A quantitative assessment of this issue in the mid‐1980s suggested that one‐half of gonorrhea cases in women were unreported or undetected; the actual case ratio in the United States was estimated at 0.8, much lower than the reported ratio of 1.4.41 Because women with gonorrhea are much more likely to be asymptomatic than men with gonorrhea, screening asymptomatic at‐risk persons identifies more infected women than men.3,9 Thus, effective screening programs2,4 and behavioral changes leading to fewer STDs in men who have sex with men11,12 may partly explain the reduction in case ratio seen among whites during this time. The more stable case ratio in blacks may indicate that screening programs have failed to reach asymptomatic infected black women or may reflect different sexual mixing patterns.
Case ratio measurements may be biased by two main factors. First, underreporting in private settings, where whites and black women are diagnosed in higher proportions than black men, could artificially raise the male‐to‐female case ratio among blacks. Second, different diagnostic practices for men and women seen in private settings, whereby women receive specific testing resulting in a laboratory report and men may be treated empirically or diagnosed with the aid of a Gram stain, may artificially lower the case ratio among whites.42
The gonorrhea data presented here are part of surveillance data gathered by CDC to follow long‐term trends in STD morbidity. These data are limited in several ways. First, data collection systems vary from state to state; thus, data are not directly comparable among states. In particular, definitions of public and private are not consistent across states. Second, these data are subject to reporting bias, which leads to underrepresentation of cases from private sources as previously discussed. Third, assessments of race‐specific trends are limited by incomplete race data, especially before 1986. Finally, the data for races other than white or black are problematic; sporadic reporting by these categories in the 1980s make trends difficult to interpret.
Recent trends in gonorrhea raise several issues for public health programs aiming to better control morbidity due to gonorrhea and its sequelae. The overall decline in gonorrhea rates most likely reflects the impact of widespread screening and treatment initiated in the 1970s and continuing today, along with changes in the population age structure and barrier contraceptive use. This decline may be reassuring but should not lead to complacency. Gonorrhea rates in the United States remain much higher than rates in other industrialized nations, and much of the overall decline in U.S. rates is due to lower rates among whites and persons over age 20. Gonorrhea remains a serious public health problem among minorities and among adolescents of all races. In its recent report on STDs, the Institute of Medicine recommended a focus on adolescents and underserved populations. Specifically, the Institute of Medicine report recommended unique approaches to the education and provision of prevention services to adolescents and disenfranchised groups who may not otherwise access health services. Coordination with other social and health‐related services should ensure that effective STD services reach these especially vulnerable populations.43 Further research should define interventions that will allow these populations to benefit from the same reduction in disease that has already occurred for most Americans.
Note: Sexually Transmitted Disease Surveillance, 1996, summarizes reported cases of all sexually transmitted diseases. It is published by the Division of STD Prevention, Centers for Disease Control and Prevention, and is available on the Worldwide Web through the CDC homepage at http://www.cdc.gov.
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*States and years excluded from race/ethnicity analyses were Georgia in 1983 and 1993‐1995; Connecticut 1984‐1986; Florida in 1981 and 1983‐1985; Illinois 1981‐1984; Idaho in 1983; Indiana 1983‐1984; Kentucky 1986‐1991; Maryland 1982‐1983 and 1989‐1991; Massachusetts in 1983; Michigan 1984‐1985; Nebraska 1982‐1986; New Jersey 1982‐1985, 1990, and 1995‐1996; New York 1981‐1996; Tennessee in 1984; Virginia 1982‐1985; Wisconsin 1982‐1985; and the District of Columbia in 1984. Cited Here...
†States and years excluded from age analyses were Georgia in 1983, 1985, and 1988‐1994; Idaho in 1983; Indiana in 1983; Maryland 1982‐1983; Massachusetts in 1983 and 1990; New York 1983‐1984; Tennessee in 1984; and District of Columbia in 1984. Cited Here...
‡Four geographic regions were defined by the Bureau of Census: West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming); Midwest (Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin); Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont); and South (Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia). Cited Here...
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Antimicrobial Agents and Chemotherapy
In vitro susceptibilities of Neisseria gonorrhoeae to fatty acids and monoglycerides
Antimicrobial Agents and Chemotherapy, 43():
Archives of Internal Medicine
Outpatient visits for infectious diseases in the united states, 1980 through 1996
Archives of Internal Medicine, 159():
Archives of Dermatology
Gonorrhea - United States, 1998 (Reprinted from MMWR, vol 49, pg 538-542, 2000)
Archives of Dermatology, 136():
Sexually Transmitted Infections
Geomapping of chlamydia and gonorrhoea in Birmingham
Sexually Transmitted Infections, 76(4):
Plos OneSexual Seroadaptation: Lessons for Prevention and Sex Research from a Cohort of HIV-Positive Men Who Have Sex with MenPlos One
Journal of Adolescent Health
Perceived versus actual knowledge about correct condom use among US adolescents: Results from a national study
Journal of Adolescent Health, 28(5):
Sexually transmitted diseases in women - Gonorrhea and syphilis
Postgraduate Medicine, 107(2):
Journal of Infectious Diseases
Unique gonococcal phenotype associated with asymptomatic infection in men and with erroneous diagnosis of nongonococcal urethritis
Journal of Infectious Diseases, 181(3):
Sexually Transmitted Diseases
Gonorrhea prevalence and coinfection with chlamydia in women in the United States, 2000
Sexually Transmitted Diseases, 30(5):
Social Science & MedicineSocial capital and rates of gonorrhea and syphilis in the United States: Spatial regression analyses of state-level associationsSocial Science & Medicine
American Journal of Preventive Medicine
Longitudinal prediction of sexually transmitted diseases among adolescents - Results from a national survey
American Journal of Preventive Medicine, 18(4):
American Journal of Public Health
Gonorrhea in the HIV era: A reversal in trends among men who have sex with men
American Journal of Public Health, 91(6):
Jama-Journal of the American Medical Association
Gonorrhea - United States, 1998 (Reprinted from MMWR, vol 49, pg 538-542, 2000)
Jama-Journal of the American Medical Association, 284(2):
Jaids-Journal of Acquired Immune Deficiency Syndromes
Examining racial disparities in HIV - Lessons from sexually transmitted infections research
Jaids-Journal of Acquired Immune Deficiency Syndromes, 47():
Archives of Dermatology
Increases in unsafe sex and rectal gonorrhea among men who have sex with men - San Francisco, California, 1994-1997 (Reprinted from MMWR, vol 48, pg 45-48, 1999)
Archives of Dermatology, 135(5):
Sexually Transmitted DiseasesEpidemiologic Trends of Sexually Transmitted Diseases in ChinaSexually Transmitted Diseases
Sexually Transmitted DiseasesGonorrhoea Surveillance System in France: 1986–2000Sexually Transmitted Diseases
Sexually Transmitted DiseasesEpidemiology of STD Disparities in African American CommunitiesSexually Transmitted Diseases
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