Introduction

Gonorrhoea is a sexually transmitted infection (STI) caused by the bacterium Neisseria gonorrhoea. It is currently the second most common bacterial STI in the world with 106 million new cases appearing annually. Its transmission is influenced by, both, behavioural and social factors, with many efforts used to improve education, access, and healthcare to counteract the rise in cases.

This article will go over the behavioural and social factors that influence the transmission of Gonorrhea.

Gonorrhoea

Cause and disease

N. gonorrhoeae is a Gram-negative bacterium (GNB), which invades epithelial cells at mucosal surfaces, causing infection. It is a difficult bacterial infection to treat due to rising resistance as well as its high surface molecule variability, allowing it to evade the host immune response and making it difficult to devise vaccines. It is what causes sexually transmitted infection (STI), gonorrhoea, which tends to cause cervicitis (cervical inflammation) in women, and urethritis (swelling of the urethra) in men. 

Transmission

The disease is transmitted via sexual contact. Transmission may occur via vaginal, anal, or oral sex.¹ 

Symptoms

Symptomatic infection tends to be much more common in men, with 90% of cases displaying symptoms. These may include:² 

• Swelling of the foreskin 
• Pain when urinating, 
• Penile discharge which could be yellow, green, or white
• Testicular pain 

For women, however, only around 50% of cases are symptomatic, showcasing symptoms such as ²: 

• Unusual vaginal discharge which could be thin/watery, and yellow/green
• Discomfort when urinating
• Abdominal pain
• Irregular bleeding 
• Heavy menstruation
• Bleeding after sex 

Diagnosis

If gonorrhoea is suspected, the patient will likely be referred to a genitourinary medicine (GUM) clinic for a swab of the mucosal areas where the sexual activity occurred. 

If a patient refuses attendance at a GUM clinic, the doctor may carry out a nucleic acid amplification test to check for the presence of N. gonorrhoea. If detected, the patient will have to have a swab taken. The swab will then be sent to a laboratory, where it will be cultured and the bacterium tested for antibiotic susceptibility before prescription. 

Treatment

There are two main drugs available for the treatment of gonorrhoea:¹

• Ceftriaxone
  • It is a cephalosporin that inhibits bacterial cell wall synthesis, causing bacterial cell death
• Azithromycin
  • It is a macrolide antibiotic that prevents bacterial protein synthesis, killing it.

Complications

If left untreated, gonorrhoea may cause complications, which is especially concerning as 50% of women tend to be asymptomatic and continue on, unaware of their disease and preventing treatment. In women, it may lead to: 

• Pelvic inflammatory disorder, which may lead to fertility issues 
• Ectopic pregnancies (embryo implants outside the womb)
• Chronic pelvic pain 

If pregnant and infected with gonorrhoea, the chance of miscarriage increases, as does the probability of premature birth. During birth, the mother may also infect the baby with gonorrhoea, causing conjunctivitis, which could lead to permanent vision damage in the baby. 

In men, the infection could spread to the testicles and prostate, causing fertility issues.³ For both genders, gonorrhoea could establish a disseminated infection, leading to sepsis, septic arthritis, and endocarditis.¹

Prevention

Considering the lack of a vaccine for gonorrhoea, the best ways of prevention are: 

• Condom usage 
• Limiting the number of sexual partners 
• Regular screenings for both you and your partners

Behavioural factors 

Sexual behaviour 

Sexual behaviour has had a large impact on the rise of gonorrhoea transmission. People nowadays tend to have a higher number of sexual partners and a lower age at first sex compared to people in the 1940s. They also tend to ‘settle down’ at an older age, increasing this period available for more casual, and frequent sexual relations. This increase in sexual partners and increased time in casual sexual activity participation has led to increased levels of gonorrhoea.⁴   

Condom use 

A major method of gonorrhoea, and any STI, prevention is the use of barrier contraception like condoms. A study testing multiple STI transmission rates against condom use showed that with correct and consistent condom usage, the risk of gonorrhoea was significantly decreased. 

Condoms must be used during each encounter and used exactly as instructed to provide maximal effectivity. Shown ways of reducing a condom’s protective effectiveness are ⁵: 

• Using a condom sporadically during encounters, 
• Condom breakage 
• Condom leakage 
• Condom flipping 
• Using a condom after sex has begun or removing it before the end of intercourse

Furthermore, people may encounter barriers towards condom use due to cultural or personal reasons, or issues in terms of availability. A study evaluating barriers to condom usage found that many people may refrain from using condoms due to ⁶: 

• Fears of their partner accusing them of mistrust 
• Inability to buy them due to embarrassment 
• High cost 
• Lack of access to a shop
• General dislike or religious beliefs 

Substance use 

The use of alcohol and drugs has been shown to correlate with increased gonorrhoea transmission. A potential reason is cognitive impairment, which will make someone less likely to consider the dangers of unprotected sex, increasing the possibility of engaging in high-risk sexual behaviours. Moreover, drug users may also trade sex for drugs, therefore engaging in more frequent sexual activity with higher-risk sexual partners.

Healthcare stigmas and accessibility 

Sexuality tends to be a more private matter, with people often preferring to keep their activities hidden, hence infections involved with sexual activity, like gonorrhoea, tend to be a more stigmatised matter. 

People are often embarrassed to admit to having an STI and fear judgment from those around them. Therefore, people are less likely to have a positive attitude towards regular screenings or seeking medical advice. 

If people don’t get screened or don’t seek medical advice due to shame, they will be unable to receive treatment and so may continue transmitting the disease to more and more people. Moreover, they may also delay notifying their sexual partners of their diagnosis, infecting their partners and allowing them to, unknowingly, spread the disease to more people.⁷ 

Social factors 

Socioeconomic status 

Communities of a lower socioeconomic status tend to have increased gonorrhoea rates due to lower access to healthcare or the inability to afford the necessary healthcare services. This tends to be especially prevalent in the USA, which does not have free national healthcare, unlike the UK. This lack of healthcare services may drive individuals to continue spreading gonorrhoea by engaging in sexual activity without having received treatment. 

Unfortunately, communities of lower socioeconomic status tend to see women being more dependent on their male partners, decreasing the woman’s ability to negotiate sex or condom use and increasing the possibility of partner infidelity.^{7, 8} 

Cultural norms and beliefs 

Cultural norms and beliefs may influence access to sex education as well as condom usage. 

Certain cultures do not believe in early sex education due to religious beliefs, making people less aware of the risks involved with sexual activity, including gonorrhoea. This unawareness may decrease their chances of using necessary preventative measures to protect themselves from acquiring and further transmitting gonorrhoea. 

Some people also do not use condoms due to religious beliefs, for example, Catholics have been advised by the Pope that artificial contraception, which involves condoms, is unacceptable.⁹ 

Urban vs. rural differences 

Rural areas tend to exhibit a lower prevalence of STIs like gonorrhoea due to a lower population, decreasing the amount of potential sexual partners as well as having better neighbourhood cohesion. However, rural areas also have worse access to healthcare making treatment more difficult should someone get infected.⁸  

Addressing behavioural and social factors 

Sex education 

Effective sex education programmes are comprehensive, teaching adolescents about methods of contraception and safe sex. They have been effective in making adolescents aware of the dangers of STIs like gonorrhoea, increasing the practice of safe sex and have also been shown to delay sexual debut amongst young people.¹⁰ 

Promotion of safe sex practices 

Promoting safe sex by providing contraception and condoms for free to both adolescents and adults in the UK has been successful in improving access to barrier methods of protection and decreasing gonorrhoea transmission. Campaigns to decrease stigma contributed to STIs have been used to encourage testing and condom use to decrease transmission.¹¹ 

Improving access to healthcare 

Gonorrhoea transmission may also be decreased by providing better accessibility to STI clinics or by providing mobile health units or telehealth services to speed up diagnosis, testing, and treatment.

Summary

• Gonorrhoea is an STI caused by N. gonorrhoea, which is transmitted by vaginal, anal, or oral sex. 
• Its transmission may be increased by many factors, behavioural and social, such as substance abuse, lack of condom use, risky sexual behaviour, stigmas, low socioeconomic status, cultural and social beliefs, and urban areas. 
• Efforts have been made to target these factors and reduce transmission through improved sex education, safe sex practice promotion, and better access to healthcare.