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Sexually transmitted infections (STIs) represent a significant public health concern. In 2018, the CDC reported that combined cases of syphilis, gonorrhea, and chlamydia reached an all-time high in the United States. Especially concerning was the notable increase in cases of congenital syphilis.1 Approximately 20 million new STI cases are diagnosed each year, with an estimated annual cost to the U.S. health care system of $16 billion. Almost one-half of these new cases occur in adolescents and young adults.

Few research studies have been conducted about STI prevalence in transgender and gender diverse (TGD) patients compared with the overall population; however, there is evidence suggesting an increased risk of rectal STIs among transgender women, particularly those who engage in transactional sex.2,3 Due to the diversity of TGD individuals with regards to gender-affirming surgical procedures, hormone use, and sexual practices, clinicians should regularly assess for STI risk based on their patients’ current anatomy and sexual health and sexual risk behaviors.4,5 Moreover, it is crucial to obtain a clear understanding of what body parts a patient has used during sexual encounters with their partner(s) to know which sites to test during a screening evaluation. Clinicians must also discuss STI screening options with their patients, including self-swabbing, which may improve comfort and thereby willingness to complete STI screening.6 The recommendations below are adapted from the 2015 CDC Sexually Transmitted Disease Treatment Guidelines.4


Infectious genital ulcers, often due to an STI, can be classified as painless ulcers (syphilis, lymphogranuloma venereum [LGV], granuloma inguinale) or painful ulcers (herpes simplex virus [HSV], chancroid). In the United States, genital ulcers in sexually active patients are most likely to be due to HSV or syphilis and can represent multiple concurrent infections. A complete diagnostic workup should be obtained with attention to diseases that may be more common based on geography or the sexual community.4 Since genital herpes infection, syphilis, and chancroid are all associated with an increased risk of HIV acquisition, HIV testing should also be included in the evaluation.4,7 Despite complete diagnostic efforts, approximately one-fourth of patients with genital ulcers have no identified etiology.4,7


Syphilis is a chronic bacterial infection caused by Treponema pallidum, renowned for its invasiveness and its ability to evade the immune system.8 The infection is characterized by three stages: primary (chancre or ulcer), secondary (rash, lymphadenopathy), and tertiary (cardiac involvement, gummatous lesions). Latent syphilis, or asymptomatic infection diagnosed by serologic testing, can be further categorized as “early latent infection” if acquired in the past year, or “late latent infection” if acquired more than a year ago or if the duration of infection is unknown. While late latent syphilis is no longer contagious, treatment prevents further complications from infection and transmission to the fetus in pregnant persons.4,8 Neurosyphilis, T. pallidum...

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