A typical STD check includes a visual inspection (looking for open sores, chancres, or pus), swabs, a blood draw for HIV and syphilis tests, and a urine sample for gonorrhea and chlamydia tests. The problem? Gonorrhea can exist in the throat or rectum without testing positive in a urine sample, and not testing these areas can lead to the STI going undiagnosed, which can further spread the disease. Not great, especially given that oral sex is at the root of the current spread of an untreatable strain of gonorrhea.
According to Howard Grossman, an internal medicine doctor specializing in LGBTQ health, doctors need to expand their testing regime. "All providers must be educated to do appropriate testing that evaluates all sites of possible infection," he wrote in an article for The Body, "and testing should be available in all primary-care settings. If your provider is not testing for oral and anal infection, then they are not testing appropriately."
For decades, Grossman ran a practice in New York City geared towards queer patients. In that time, he saw the need for increased surveillance of STIs as a way to help gay people pursue sexual freedom safely. Now at Cleveland Clinic's location in Florida, Grossman continues to advocate for increased, and more thorough, testing of STIs as a way to prevent their spread. "We are in the middle of this STI epidemic because we aren't testing enough and we aren't testing properly," he says.
Testing properly means that if a patient has had a dick in their throat or ass, they should have swabs of those areas to test for gonorrhea. The standard urine test is good for heterosexual men who are most likely to have gonorrhea in their urethra, but for women and gay men, gonorrhea can remain undetected.
One barrier to more effective gonorrhea screening is the efficacy of the current tests beyond the urine sample. The NAAT (nucleic acid amplification test) is primarily for the detection of urethral gonorrhea. The CDC recommends the NAAT for rectal and oral swabs of men who have sex with men. The NAAT has been shown to detect gonorrhea from these swabs, but it is not technically an FDA-approved detection method. To simplify the test, Grossman says oral and rectal swabs can be mixed in with a urine sample. This method tests multiple areas in a single lab screening. This means that a patient may not know if they have urethral, oral, or rectal gonorrhea if the test comes back positive; however, the treatment for all three is the same. This kind of sample mixing could be one way for clinicians to simplify expanded testing.
Grossman cites other possibilities to expand STI testing to reduce their spread. This might look like a Rapid-Swab type test in the doctor's office, similar to what is used to detect strep throat. Mail order testing kits are another possibility for patients who may not have easy access to a doctor, such as in very rural areas. Clinics with free walk-in services and quick results can test and treat people in the course of a short visit. This type of clinic acknowledges that people (especially gay men) have risky sex and need healthcare that accommodates this reality without judgement.
"We need to teach providers that sexuality and sexual health are integral to a person's well being. We need to make them more comfortable talking about these issues," Grossman says. That issue of clinician comfort is a big part of the gap in proper STI screening. Training on STIs and sexual health is woefully inadequate in medical school, and many students are left to learn these issues in courses outside their required training. Without proper schooling, doctors simply don't have the language to deal with these issues. They may not know how to take a full sexual history. They may not know how to ask sexual questions in a way that doesn't feel judgmental. Patients may feel awkward bringing up these issues because they are so personal. Doctors may feel even more awkward bringing them up because they don't fully understand how to talk about them.
If you think you are embarrassed about getting an anal swab at your doctor's office, think how embarrassed they might be if they've never done one before. We view our doctors as infallible experts, but there might be gaps in their knowledge. Sometimes patients need to step up and initiate the change. Next time you are getting an STI test, ask for a swab of your throat and rectum. If your doctor doesn't know to include this in a standard screen, find someone who does.