Shorts (scroll for article)

1. Shorts (scroll for article)
2. Introduction
3. History
4. Types
5. Treatments
6. Prevention & Eradication
   1. Eugenics
   2. Comprehensive Sex Ed & Safe Sex
   3. Abstinence Only
7. What you can do
8. Sources
9. Footnotes

Introduction

Syphilis is a sexually transmitted infection caused by a bacterium (Treponema pallidum), passed via painless round sores called chancres on the genitals or the mouth. Syphilis chancres can easily go unnoticed and even without treatment they go away, but the person is still infected. The disease has latent periods but can become active months, years, or decades later with more severe illness of secondary and tertiary syphilis. These later stages can leave scars on bones, cause organ damage, and death. It wasn’t until 1943 that penicillin was discovered to cure syphilis, and today this is still the most common treatment: two doses of penicillin (with alternatives for people who are allergic).

Famous cases include Al Capone’s decline caused by neurosyphilis, resulting in paresis, which is a consequence of tertiary syphilis. As well as the infamously, shamefully unethical medical experiment: “Tuskegee Study of Untreated Syphilis in the Negro Male” carried out without informed consent and despite knowing how syphilis progresses if untreated, between 1932 and 1972 by Tuskegee University in Alabama, continued decades after doctors had discovered a cure.¹

During pregnancy, syphilis can cross the placental barrier and infect the fetus. Congenital syphilis can lead to miscarriage, stillbirth, low birth weight, and neonatal death. Survivors face life long health problems like cataracts or blindness, deafness, seizures, skeletal deformities, severe anemia, heart and other organ damage. Among the skeletal deformities include the teeth, with children developing pegged or a crescent shaped notches, called Hutchinson’s teeth, which is even more noticeable on permanent teeth. Congenital syphilis can also cause distinctive facial traits, like a “saddle nose” and strong brow ridge, as well as being born with disfiguring scars.

Today, syphilis and congenital syphilis are on the rise: the CDC reported 203,500 cases of acquired syphilis in 2022, an 80% increase from 2018, and 3,755 cases of congenital syphilis in 2022, an 154% increase since 2018. At the same time, epidemiologists are warning that syphilis is becoming more virulent and developing antibiotic resistance.

History

When did syphilis emerge? There is some debate on this point. For some time there have been three schools of thought:

• The Columbian Hypothesis
  • Syphilis evolved in New World populations and was contracted and brought back to Europe by Columbus’s sailors and captive Native Americans. This is supported by 15th and 16th century sources who claimed it was a new and terrible disease that had to have come from somewhere else. There have been skeletal remains from pre-Columbian era with signs of syphilis, and more recently DNA showing that it was indeed Treponema.
• The Pre-Columbian Hypothesis
  • Syphilis already existed in the Old World and simply mutated into a new virulent form in the late 15th and early 16th century, which is when it was distinguished from other skin ailments (all called leprosy) with a unique name: syphilis. Proponents have skeletal remains with lesions and teeth deformities that resemble those in people with syphilis, from antiquity through the middle ages.
• Unitarian Hypothesis
  • Suggests that syphilis was everywhere, entering human population during early migratory waves (prior to humans crossing from Asia to the Americas) and that different subspecies adapted for different environments.

As noted above, syphilis wasn’t given a name until the 16th century, prior to this in Europe, all skin conditions were leprosy. Syphilis got it’s name in 1530 from an Italian poet, Girolamo Fracastoro, but he wasn’t giving credit to Native Americans, rather his poem’s title was “Syphilis, Sive Morbus Gallicus.” (“Syphilis, or the French Disease“). But blaming the French wasn’t his idea, forty years before, the Italian poet Antonio Cammelli, was suffering from full body of open blisters from syphilis, he described his look thusly:

“I am dressed as a French man,…seriously wounded over and under and front and aside/Within the whole flesh of my body.”

This habit of human groups blaming those-people-over-there for nasty conditions goes all the way back through history. In his MD thesis² written in 1938, Ivan Sterns compiled the historiography of syphilis, showing how Japanese scholars claimed it was brought to their lands by Chinese sailors; the ancient Aruvedic (India) descriptions of a syphilis-like condition was called “Persian fire” because they believed it came from Persia. And there are many other examples, many Europeans called it the French pox or the Neapolitan disease.

But backing up for just a moment, you may have noticed that there’s some inconsistency in the description of syphilis. Today, primary syphilis is easy to miss because the chancres are small and don’t hurt, you may not even notice them (at least not without a couple of mirrors) but Cammelli claiming he’s “seriously wounded over and under,” or ancient Indians calling it “Persian fire”? There are some theories about why this may be: a novel infection brought to Europe would be more virulent because the population has no immunity; a novel variant of a bacterial infection is bound to be more virulent at first (if it an STI makes it’s host too ill to engage in sexual activity, there goes the transmission rates: it fails, dies out while the less virulent forms take off).

Types

There are multiple conditions caused by treponema bacteria, called treponematosis, depending on which strain is contracted and when (i.e. during development).

Endemic syphilis (also called bejel) is caused by subspecies endemicum which is spread through contact though not necessarily sexual contact. Sharing clothing, bedding, dishes, and the typical contact of a household or family unit can spread it. Most common in arid, hot environments in the eastern Mediterranean and west Asia.

Yaws is a chronic disfiguring infection caused by subspecies pertenue, affecting children who become infected through minor abrasions which develop into deep ulcers that can affect muscles and bone tissue. It is treated with a single dose of azithromycin and humans are the only reservoir yet in fifteen countries yaws is endemic.³ (We have had the technology to eradicate this condition for at least 40 years and haven’t.) It is most common in humid and warm environments, like the tropics, found in Africa and South America.

Venereal syphilis is caused by subspecies pallidum (yes, its government name is Treponema pallidum pallidum, like our species is Homo sapiens sapiens.) This is what most of us today think of when we think of syphilis, a sexually transmitted infection causing painless chancres on the genitals, and without treatment periods of latency with secondary and tertiary waves of active illness potentially over decades. Venereal syphilis leads to congenital syphilis, while the other treponematoses do not.

Recent DNA discoveries have shown that all current treponema strains’ genomes differ only 0.03% and they ultimately cause similar symptoms though the location of chancres differs by subspecies and when contracted in utero. Even in advanced cases, that is without treatment, between 5-30% develop skeletal traces, so it is very difficult to identify from human remains alone where and when syphilis was present in history and geographically. Plus, many other conditions can leave similar bone lesions– which makes the skeletal evidence cases for and against the pre-Columbian and Columbian hypothesis moot. DNA evidence or bust. And this is the tricky bit, its the late stage of syphilis that’s most likely going to leave evidence of infection in the bones, but late stage syphilis are the hardest cases to find the bacteria, even in living people. The most likely source of bacteria for genomic testing are infected neonates and neonatal remains rarely survive in the archeological record.

In 2020, research was published about the genetic diversity of treponema in Early Modern Europe, they found that there were a variety of strains related to both venereal and yaws causing treponema in Northern Europe, plus a previously unknown “sister” strain to the yaws and bejel subspecies.

Treatments

Well into the 20th century treatment for syphilis involved mercury, arsenic, bismuth, and other heavy metals including during pregnancy and for newborns with congenital syphilis. In a 1937 film by the AMA and the United States Public Health Service, Syphilis: a motion picture clinic, they claimed that they could prevent maternal transmission of syphilis to the fetus if the arsenic, etc. treatments began before the fifth month of gestation. If babies were born with congenital syphilis they were started on similar regimens involving mercury, arsenic, and bismuth.

It wasn’t until 1928 that penicillin was discovered as an antibiotic and not until a chance discovery in 1943 that doctors at the U.S. Marine Hospital on Staten Island realized penicillin cured syphilis. This is still the treatment used today to cure syphilis, with alternatives for people who are allergic to penicillin.

Prevention & Eradication

Eugenics

We cannot discuss the history of syphilis without eugenics. The eugenics movement initially began with the goal of preventing congenital problems, like “inherited ” syphilis (eu- good, genics- birth). With regards to syphilis, the public were taught, often at large shows like the Philadelphia Baby Saving Show in 1912, what to look for symptom-wise and those diagnosed with the disease were warned not to marry until they could prove they were “cured” (a negative test) to prevent babies born with the condition. (In the film Syphilis: a motion picture clinic from 1938, there is a scene showing how a man and his doctor should have a meeting with the new fiancé to discuss his previous syphilis diagnosis and apparent cure, and what she should do once she’s expecting a baby.)

Eugenics marriage laws began being passed in the 1910s across the United States, requiring couples to have a negative blood test for syphilis before they could get a marriage license. But by the 1980s, the laws began to be dropped because it seemed of little public health benefit for the hassle, after all people can and do have sex and babies outside of marriage.

Comprehensive Sex Ed & Safe Sex

Through the 1990s, with the emphasis on comprehensive sex education in public schools and public health messages about safe sex (which were usually directed at reducing HIV transmission, helped prevent most STIs) the cases of syphilis continued to decline.

I’m old enough to remember TLC wearing condoms (in wrappers) as fashion accessories. At my small midwestern high school, the school nurse kept containers of condoms for anyone to take a few. Through comprehensive sex education, my classmates and I understood both the benefits and limitations of condoms when it came to STIs, and how to use them when or if we decided to have sex. We also learned how we could get reproductive healthcare (contraception, STI screenings, annual exams, etc.) for no cost and without necessarily involving our parents.

All together, these programs and popular messages about safe sex helped reduce the rates of other STI’s and teen pregnancy, and brought rates of syphilis to a historic low in 2000 and 2001. My 2002 copy of What To Expect When You’re Expecting confidently proclaims:

“The very good news is that mother-to-baby transmission of syphilis is down dramatically. In fact, the CDC is optimistic that this trend is a sign that syphilis will soon be wiped out in the United States.”

-Murkoff, Eisenberg, & Hathaway. 2002. What To Expect When You’re Expecting.

Abstinence Only

Then the Bush administration (2001-2009) got involved with sex ed in public schools. While abstinence was part of comprehensive sex education curriculums in the United States in the 1990s, President George W Bush forced the issue: no longer would comprehensive sex ed be supported, funding would be for abstinence-until-marriage-only programs, if any sex-ed was taught at all. (And at the time, same-sex marriage was illegal, so the message for homosexual students was that they could never have “safe” sex.)

Even if telling teenagers that the only way to be safe from STIs and unplanned pregnancy was abstinence-until-marriage made them not have sex until they were married (and they avoided sexual assault and were never sexually abused)– what about the young heterosexual virgin-til-married couples who want to plan their families? or who aren’t sure why they are having trouble conceiving? or simply don’t understand how their or their spouse’s body work sexually?

Highschool is the last stage of compulsory education for Americans, if young Americans don’t get sex education during high school then they likely never will. Its not just about STIs and contraception either, its about understanding human biology, learning about self-exams for cancer, about what is within the range of healthy and what should be evaluated by a doctor. No one with comprehensive sex ed would believe that the female reproductive system is “at will” and can be shut down in the case of sexual assault or that menstruation can be held back or sped up, or that ectopic pregnancies can be reimplanted in the uterus.⁴ The benefits of comprehensive sex education to everyone: to the individual, couples, families, communities, to the nation, to the world, should be obvious regardless of politics or religion.

In 2001, the scientific data was already clear that abstinence-only programs do not help reduce harm and they don’t reduce sexual activity of teens or unmarried twenty-somethings. Everyone with a scientific background in the subject rejected the changes imposed by the Bush administration because of the harm it would inevitably cause, including the ACLU and the Guttmacher Institute. In February of 2002, the National Coalition Against Censorship wrote an open letter to the President, drafted by the Advocates for Youth,

The most trusted medical and scientific institutions in our nation,
such as the American Medical Association, the American Academy
of Pediatrics, the Society for Adolescent Medicine, the Institute
of Medicine, the American College of Obstetricians and Gynecologists,
the American Nurses Association and the American Public Health
Association, all recommend sexuality education that includes
age-appropriate and medically accurate information about abstinence
and contraception.

In fact, the Institute of Medicine recommends that “Congress, as well
as other federal, state, and local policymakers, eliminate
the requirements that public funds be used for abstinence-only
education, and that states and local school districts implement
and continue to support age-appropriate comprehensive sex
education.”

NCAC, 7 Feb 2002.

So what was the result of sweeping away comprehensive sex ed and replacing it with abstinence-until-marriage and those expensive, sadistic, point-missing, infant abuse promoting Baby Think It Over dolls? Rising rates of STIs, including HIV⁵, and unplanned pregnancies (and not just in the United States but overseas as well). Less than a generation later, the CDC reported 203,500 cases of acquired syphilis in 2022, an 80% increase since 2018. They also reported 3,755 cases of congenital syphilis in 2022, a horrific 184% rise since 2018.

What you can do

Congenital syphilis is entirely preventable, even if you can’t pay for medical care, there are programs available specifically to help cover the costs of prenatal care and local public health departments will be able to help you with more information on screening for syphilis. Getting treatment early in pregnancy nearly always prevents the development of congenital syphilis.

According to recent news article, American Academy of Obstetricians and Gynecologists (ACOG) previously recommended syphilis screenings only in late pregnancy and only to those in high risk groups (e.g. geographical regions with high number of cases, or individuals with high risk lifestyles). Yet in reference books from 1976 and 2016 both said all women were tested during their first prenatal visit and that only the later tests were dependent on high risk factors.

Regardless, now ACOG are advising routine screening during first prenatal visit, again in 3rd trimester, and at birth (they say this could have prevented 90% of congenital syphilis cases of the past few years). If the mother was recently infected with syphilis, perhaps when she conceived, early treatment, that is treatment prior to the 4th month of gestation can prevent the fetus from contracting the condition. However, one of the reasons for testing multiple times during pregnancy is that very recent infections may not be detected by current tests.

Question for readers: If you have had a midwife assisted home birth or unassisted birth, did your midwife test you, or did you (or your partner) get screened for syphilis during pregnancy?

There is no reason to feel ashamed or frightened of testing positive for syphilis; getting tested and seeking treatment are the actions of a responsible, informed person. Shifting feelings of shame to a sense of gratitude can help, at the moment we have the technology to test and treat it quickly. For centuries (possibly longer) there was no cure (save years of poisoning oneself with heavy metals) and couples suffered the loss of pregnancies and newborns, or had children with serious disabilities and disfigurements without understanding why it was happening or how to prevent it.

Today, syphilis is treatable and congenital syphilis is preventable, during pregnancy syphilis is treated with two doses of injected penicillin (with alternatives for people who are allergic to PCN) which can be given at the same time. However, there are concerns about a shortage of penicillin as well as a rise antibiotic resistant strains– so the fewer people get infected the better. Despite access to testing and treatment, practice safe(r) sex, use protection and ideally, before trying to conceive, both partners should be tested for syphilis and other STIs and treated if necessary.

Sources

CDC Syphilis detailed STD Facts (archived)

CDC Syphilis Treatment guidelines

Donovan, Julia. 18 April 2024. “Uptick in Colorado syphilis cases impacts newborn babies.” KRDO.

Harper, Kristin N. et al. 2011. “The Origin and Antiquity of Syphilis Revisited: An Appraisal of Old World Pre-Columbian Evidence for Treponemal Infection.” Yearbook of Physical Anthropology 54: 99-133.

Majander, K.; et al. 2020. “Ancient bacterial genomes reveal a high diversity of Treponema pallidum Strains in early Modern Europe.” Current Biology 30 (19), 2020.07.058, pp. 3788 – 3803.e10

Portwich, P. July 1998. “Das Flugblatt des Nrnberger Arztes Theodoricus Ulsenius von 1496.” (“The broadsheet of the Nuremberg doctor Theodoricus Ulsenius from 1496.”) Berichte zur Wissenschaftsgeschichte (Reports on the History of Science), 21(2-3), p175-83.

Staff. 29 Aug 2000. “Study: Medieval Skeletons Had Syphilis.” ABC News.

Stearns, H. Ivans. 1938. “The History of Syphilis.” University of Nebraska Medical Center (MD Thesis)

Sunny, Suneeta. 19 April 2024. “Surge in Newborn Syphilis Cases Prompts Call For More Screening During Pregnancy.” Medical Daily.

Ungar, Laura. 18 April 2024. “As syphilis cases among US newborns soar, doctor’s group advises more screening during pregnancy.” AP/ 4029 News.

University of Zurich. 13 Aug 2020. “Syphilis May Have Spread Through Europe Before Columbus.” Max Planck Institute.

Footnotes

1. https://www.cdc.gov/tuskegee/timeline.htm ↩︎
2. If you are interested in historiography of syphilis, I highly recommend reading Ivan Stearns thesis (link in sources). It’s fascinating look at what historians understood about syphilis almost a century ago. ↩︎
3. https://www.who.int/news-room/fact-sheets/detail/yaws ↩︎
4. In 2012, Rep Todd Aiken of Missouri claimed that in cases of “legitimate rape” the female body prevents conception, therefore there was no need for abortion in cases of rape. In 2015, according to a Mumsnet message board, a male teacher told his 15 year old female student that she couldn’t go to the bathroom and should “hold in” her period until the end of class. In 2019, the Ohio state legislature introduced a bill requiring ectopic pregnancies be reimplanted in the uterus. ↩︎
5. For people aged 13–29 years, there was a 21% increase in HIV just between 2006-2009. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3149556/ With African American male to male transmission accounting for nearly half of the new infections (its not like they could access protection–y’know, a marriage license). https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-17-4.pdf During the 00s there were around 50k new infections a year but in 2021, there were only 32k new infections, a 12% decline since 2017, and the 13-24 year old age bracket accounts for 34% of that decline. https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics ↩︎