Emerg Infect DisEIDEmerging Infectious Diseases1080-60401080-6059Centers for Disease Control and Prevention18258070260016607-111210.3201/eid1401.071112PerspectiveSexual Health and Sexually Transmitted Infections in the North American ArcticSexual Health and Sexually Transmitted Infections in the North American ArcticSexual Health and STIs, the ArcticLawDionne Gesink*RinkElizabethMulvadGertKochAnders§University of Toronto, Toronto, Ontario, CanadaMontana State University, Bozeman, Montana, USACentre for Primary Health Care, Nuuk, GreenlandStatens Serum Institut, Copenhagen, DenmarkAddress for correspondence: Dionne Gesink Law, Department of Public Health Sciences, Health Sciences Bldg, University of Toronto, 155 College St, 6th Floor, Toronto, Ontario M5T 3M7, Canada; email: dionne.gesinklaw@utoronto.ca1200814149

STI rates reported for the Arctic are much higher than those reported for their southern counterparts.

Our objective was to describe the basic epidemiology of sexually transmitted infections for Arctic and sub-Arctic regions of North America. We summarized published and unpublished rates of chlamydial infection and gonorrhea reported from 2003 through 2006 for Alaska, Canada, and Greenland. In 2006, Alaska reported high rates of chlamydial infection (715 cases/100,000 population) compared with the United States as a whole; northern Canada reported high rates of chlamydial infection (1,693 cases/100,000) and gonorrhea (247 cases/100,000) compared with southern Canada; and Greenland consistently reported the highest rates of chlamydial infection (5,543 cases/100,000) and gonorrhea (1,738 cases/100,000) in the Arctic. Rates were high for both men and women, although the highest incidence of infection was predominantly reported for young women in their early twenties. We propose that community-based participatory research is an appropriate approach to improve sexual health in Arctic communities.

Keywords: Arcticaboriginal healthsexual healthsexually transmitted diseasescommunity-based participatory researchperspective

Four million people live in the Arctic (1), yet little is known about sexual health and sexually transmitted infections (STIs) in the circumpolar North. Arctic communities in North America comprise a large proportion of Native American, First Nation, Metis, Inuit, and other aboriginal peoples living in harsh climates, diverse landscapes, and a variety of community structures including urban, micropolitan, reserves or reservations, towns, villages, settlements, and remote fly-in communities. Access to healthcare varies by community and country and patient concerns about the preservation of confidentiality remain a barrier to accessing healthcare.

STI intervention and prevention strategies have been developed primarily for urban and suburban environments (2,3), the rural South (47), Latino communities (8), and developing countries, primarily in Africa (9,10). Cultural differences alone will affect their generalizability to communities in the Arctic. This is further emphasized by Bjerregaard et al. (11) who stated: “Intervention models developed under quite different circumstances cannot be expected to work in Greenland and intervention studies are highly needed.” However, combining the global knowledge gained from previous interventions involving other populations with the local knowledge and infrastructure of Arctic communities is important to develop innovative, culturally appropriate, and sustainable STI intervention strategies.

Our objective was to describe STI trends in the circumpolar Arctic, focusing on the North American continent (United States, Canada, and Greenland). We also propose a community-based participatory research approach to conducting research and planning interventions involving Arctic communities.

Methods

Data on chlamydial infection and gonorrhea in the United States, Canada, and Greenland were collected from a variety of sources. Rates for the United States and Alaska were obtained from federal (12) and state (13) reports. Rates for Canada were obtained in collaboration with the Public Health Agency of Canada STI Surveillance and Epidemiology Section (Public Health Agency of Canada, unpub. data; see also [14] for published summaries). Data reported for Canada’s northern territories (Yukon, Northwest Territories, and Nunavut) were combined into 1 statistic and compared to data reported for Canada’s southern provinces, which were also combined into 1 statistic. Data for Greenland were obtained from the Office of the Chief Medical Officer in Greenland (15,16) and compared with data reported for Denmark by the Statens Serum Institut (www.ssi.dk). In situations where STI rates were not already available (primarily Greenland and Denmark), rates were calculated by dividing the number of cases by the total population and multiplying by 100,000. Population estimates were obtained from the US Census Bureau, Statistics Canada, Statistics Greenland, and Statistics Denmark (StatBank).

Chlamydial infection and gonorrhea rates reported for the year 2006 were standardized by age and sex to the year 2000 US population so that rates could be compared across countries after correcting for age and sex differences between the different populations. Rates were standardized to the year 2000 US population by using age- and sex-stratified counts available from the US Census Bureau (www.census.gov). Additionally, chlamydial infection and gonorrhea rates were stratified by the basic demographic characteristics of age, sex, and race (when available) to gain insights into target populations for community interventions. Rates by race were only available for Alaska.

Results

As expected, chlamydial infection was the most highly reported STI for the United States, Canada, and Greenland (Table 1). Compared with other states in the United States, Alaska reported the highest rates of chlamydial infection in 2003 and second highest in 2004 and 2005 (12). Canada’s northern territories consistently reported the highest rates of chlamydial infection in Canada, which is consistent with the 1987–1994 rates measured by Orr and Brown (17) for the Keewatin District of the Canadian Central Arctic. Greenland reported chlamydial infection rates higher than Denmark and higher than any other country in the North American Arctic.

Comparison of sexually transmitted infection rates reported for North America’s Arctic countries, 2003–2006
Yearly rate*United StatesAlaska, USACanadaNorthern territories,†
CanadaSouthern provinces,† CanadaDenmarkGreenland
Chlamydial infection
2003301.7601.1189.41,4331853423,255
2004316.7609.4197.11,8051954013,208
2005332.5664.4200.41,9521954414,762
2006347.8682202.21,9221974584,527
2006 standardized‡
470.9
715
205
1,693
200
681
5,543
Gonorrhea
2003115.288.326.0264253.51,162
2004113.587.428.9215297.71,148
2005115.691.527.8212288.21,350
2006120.99533.1281327.51,418
2006 standardized164.410133247326.51,738

*Per 100,000 population. Data from Centers for Disease Control and Prevention, 2006 (12); Public Health Agency of Canada, 2007 (14); Office of the Chief Medical Officer in Greenland (15,16); Statens Serum Institute surveillance Epi-data online (www.ssi.dk).
†Canadian Northern territories: Yukon Territory, Northwest Territories, and Nunavut; Southern provinces: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Quebec, Newfoundland, Nova Scotia, New Brunswick, and Prince Edward Island.
‡2006 standardized estimates are directly standardized to the year 2000 US population distributed by age and sex.

Co-infection with chlamydial infection and gonorrhea is common so we expected gonorrhea rates to be high for the Arctic regions. However, Alaska reported some of the lowest gonorrhea rates in the United States (12). As expected, however, the Canadian Northern Territories reported higher gonorrhea rates than their southern counterparts, and again, Greenland reported gonorrhea rates higher than those in Denmark and in any other country in the North American Arctic (Table 1).

Chlamydial infection rates reported for women were much higher than rates reported for men in Alaska (Table 2), Canada (Table 3), and Greenland and Denmark (Table 4). Compared to gonorrhea rates reported for men, however, gonorrhea rates were higher for women <30 years of age in Alaska (Table 2), <20 years of age in Canada (until 2006, when rates remained higher for women <24 years of age; Table 3), and <20 years of age or <30 years of age for women in Greenland (Table 4). Gonorrhea rates reported for men in Denmark were consistently higher than rates reported for women (Table 4). Reported rates of chlamydial infection and gonorrhea were consistently high for both men and women 15–30 years of age, particularly for those 20–24 years of age, regardless of country.

Chlamydial infection and gonorrhea rates per 100,000 population by age, sex, and race reported for Alaska, 2006*
CharacteristicChlamydial infection rates
Gonorrhea rates
MFMF
Age, y
15–199664,15878346
20–242,6734,990344496
25–291,2502,253185309
30–34607854162162
35–39
269
420

134
81
Race
White2353892841
Alaska Native/
 American Indian9273,012153344

*Source (13).

Chlamydial infection and gonorrhea rates per 100,000 population by age and sex reported for northern territories (NT) and southern provinces (SP) in Canada, 2004–2006*
Characteristic2004
2005
2006
NT
SP
NT
SP
NT
SP
MFMFMFMFMFMF
Chlamydia, age, y
<1422319119223610.8188296116
15–193,05010,0142761,4283,19311,8662701,3673,37410,7712781,329
20–244,7789,4086951,4785,2558,8937011,4704,9829,4317031,475
25–293,1544,4924055523,6234,4354235623,1925,024419592
30–391,2921,9131411581,4611,8561571581,6971,812164170
40–59338359312248645034213994323624
>601201424190215418412652
Total
1,190
2,451

128
260

1,339
2,595

132
256

1,312
2,556

134
258
Gonorrhea, age, y
<14023027380302304
15–1937676157124437737531126711,47363132
20–24820763126999686501181021,0381,246132118
25–297383329143689433934155752610457
30–3930616965143118661152672346721
40–591371523371452328625270
>602404022040422550
Total240189372123918435202513124025

*See (14).

Chlamydial infection and gonorrhea rates per 100,000 population by age and sex reported for Greenland (GLD) and Denmark (DK), 2004–2006
Characteristic2004
2005
2006
GLD
DK
GLD
DK
GLD
DK
MFMFMFMFMFMF
Chlamydia, age, y
15–199,37820,3329443,3617,98631,3831,2433,89112,46227,1251,3454,095
20–2413,22916,8901,9663,5269,00320,5942,2643,72017,15421,8542,3913,768
25–296,4448,5909781,2845,77611,0061,0891,32210,83710,4451,1141,335
>309161,22986418051,00585871,6301,5079388
Total
2,481
4,158

287
511

3,852
5,597

324
554

3,704
5,468

343
571
Gonorrhea, age, y
15–193,7147,34613.97.72,1417,80111.54.05,3608,76311.16.5
20–244,6634,45046.47.42,9935,64839.913.15,9945,85832.516.0
25–293,0561,79551.34.51,9843,18444.94.73,7552,37439.410.8
>3049343410.71.222431214.11.136349812.41.2
Total1,0471,30113.61.91,1741,55014.62.01,2521,60912.52.6
Discussion

Chlamydial infection rates were higher for Arctic and sub-Arctic areas in North America than for their southern counterparts. Gonorrhea rates reported for northern Canada and Greenland were also much higher than for their southern counterparts, although rates reported for Alaska were not very high. In 1741, Hans Egede, the first missionary to Greenland noted that “It is strange. . . that even though [Greenlanders] have free intercourse with other people, these are not infected” (11). However, for the past several years Greenland has reported chlamydial infection rates ≈10× higher, and gonorrhea rates ≈100× higher, than rates reported for Denmark and the highest rates of both infections in the North American Arctic (Table 1).

Chlamydial infection and gonorrhea rates reported for the Arctic and sub-Arctic are very high for both men and women, although the highest incidence of infection is predominantly reported for young women in their early 20s (Tables 24). True rates could be higher than reported for a variety of reasons. As in other settings, asymptomatic infection is high for both men and women and can result in missed cases. How much knowledge exists in remote communities about STIs, their symptoms, and what to do if one suspects he or she has an infection is unclear. Even if a person suspects that he or she has an infection, accessing healthcare can be a challenge since many of the Arctic communities are remote fly-in communities with limited healthcare resources. Additionally, many Arctic residents spend their summers away hunting or whaling, usually at great distances from their communities, and certainly far away from a healthcare provider. Another barrier to care in small communities is the issue of confidentiality and the common perception that it can be breached easily. This results in delayed healthcare seeking or missed infections. Partner notification can also be hindered by cultural norms and taboos. For instance, in some communities, talking about something can be regarded as the same as wishing it upon the people. Therefore there can be a reluctance or even movement against talking about STIs or naming sexual contacts. Finally, reporting infections can become a challenge in an already overtaxed healthcare system with limited infrastructure.

STI rates are quite variable across the North American Arctic and sub-Arctic (Tables 14). Access to healthcare and reporting differences could explain some of the difference in rates. For instance, Greenland has universal healthcare. Canada has universal healthcare, but it differs for on-reserve and off-reserve aboriginal people. Alaska only has universal healthcare for indigenous people. These different healthcare coverage strategies could affect the healthcare-seeking behavior of the populations that live with them. Another nuance of northern rates is the small underlying populations from which cases arise. The addition of 1 new case can result in a large change in the rate of infection. Additionally, because no international surveillance system is in place to monitor STIs, the information collected is not standardized between the countries. For instance, in the United States, the only country that collects racial information as part of its surveillance program, chlamydial infection, gonorrhea, and syphilis rates reported for American Indians and Alaska Natives were recently reported to be 2–6× higher than rates reported for non-Hispanic whites (18). In Canada, STI rates are suspected of being higher for aboriginal people, but no data exist to confirm this hypothesis. In Greenland, 89% of the population is Kalaallit Inuit, making it of arguable importance to collect racial information for Greenland.

There is a dearth of research pertaining to the factors that contribute to sexual health and STIs among aboriginal people (18,19). Chlamydial infection and gonorrhea are major causes of ectopic pregnancy in the Canadian Arctic (17), and STIs are highest for Canadian aboriginal people 15–24 years of age (20). Westernization, culture, and identity have been suggested as possible factors influencing STI transmission among Inuit youth in northern Canada (20); however, research is still needed to provide evidence for this hypothesis. Most other studies have focused on HIV and AIDS (19,21).

In Greenland, much of the STI research has also focused on HIV/AIDs. HIV/AIDS came late to Greenland compared to the rest of Europe and has remained limited to a heterosexual, alcohol-abusing group of persons of low socioeconomic status living in 2 communities in western Greenland. One reason that HIV, unlike other STIs, has not become a widespread epidemic across Greenland is because the prevalence of needle sharing and men who have sex with men is limited, considerably affecting the modes of transmission (11). However, research on HIV transmission among heterosexual persons, as well as the increased risk for co-infection with STIs and HIV, suggests that chlamydial and gonorrhea rates in Greenland are a public health concern that warrant further investigation (2224).

As suggested by Steenbeek et al. (20), colonization and westernization in the Arctic may be responsible for increased rates of STIs for Arctic communities. We further hypothesize that these factors are contributing to disparately high STI rates in the Arctic through individual, familial, social, cultural, and environmental domains. We also hypothesize that high STI rates may only be a marker of greater underlying public health concerns such as substance abuse, poor mental health, and the legacy of historic trauma.

Implications for Future Research

We propose that community-based participatory research (CBPR) is an appropriate approach to address sexual health and STIs in the Arctic. Sexual and reproductive health data for aboriginal populations are often not reported in national surveillance and survey reports (25). Also, indigenous communities have historically been reluctant to participate in research projects because traditional research methods, which emphasize the researcher as “the expert,” have not engaged indigenous communities in designing and implementing research projects (25). CBPR has been identified as an effective and essential strategy for conducting research with indigenous peoples because of its emphasis on community participation to build ownership of research projects and community-based interventions as well as empowering the community to address its health disparities (26,27).

Several components of CBPR support its use as a methodologic framework for conducting research in aboriginal communities. First, CBPR engages aboriginal or indigenous people in full and equal partnership with those communities in efforts to observe and respect tribal sovereignty and the right to self-determination (28). Second, the growing interest in addressing the interrelatedness of historic trauma and health disparities in indigenous populations and the inherent complexities of unraveling the interconnected components and concepts related to historic trauma and health can best be understood by discussions and conversations with indigenous communities (29,30). Third, a legacy of harm from past research, as well as mistrust of researchers, warrants the use of CBPR as a means to ensure that all phases of a research project, from the development of research questions to research design and data collection methods to dissemination of results, have community input and approval (26,31). Fourth, CBPR provides a forum to ensure timely communication of research results to the community by using information dissemination mechanisms that best meet the community’s needs. Finally, the limited research on sexual health among indigenous populations primarily focuses on problem theory that provides insights into the predisposing, enabling, and reinforcing factors related to engagement in high-risk sexual behavior among aboriginal communities. However, emerging evidence in the field of aboriginal sexual health suggests that a risk-based approach to understanding sexual behavior in these communities not only has a narrow and negative focus, with scant opportunities for indigenous groups to capitalize on their strengths, but also is not congruent with indigenous cultural and social beliefs and historical experiences (32). CBPR, because of its collaborative nature, empowers community members to capitalize on the strengths and resources available in their community.

Conclusion

The use of CBPR as a framework in which to conduct sexual health research with and among indigenous populations is a promising approach that joins the strengths and skills of researchers with local knowledge, wisdom, traditions, and resources. The CBPR approach is much like taking a Bayesian approach to study design, data collection, analysis, interpretation, dissemination, and follow-up. Researchers provide global (prior) knowledge that is then integrated and updated with local (likelihood) knowledge provided by the community to produce a more holistic model of health. This approach means that study designs can be more effective, data collection can be more accurate and complete, interpretation of the results can be more insightful and relevant, dissemination of the study results can be more efficient and translated at the appropriate level for the community by community members, and interventions can be more effective, culturally appropriate, and sustainable. Community involvement in the project can also help facilitate translation of the research findings into clinical and political practice.

Suggested citation for this article: Gesink Law D, Rink E, Mulvad G, Koch A. Sexual health and sexually transmitted infections in the North American Arctic. Emerg Infect Dis [serial on the Internet]. 2008 Jan [date cited]. Available from http://www.cdc.gov/EID/content/14/1/4.htm

Acknowledgments

We thank Gaya Jayaraman for providing us with access to unpublished surveillance data for Canada, Flemming Stenz and Jytte Hey for providing us with access to published and unpublished data for Greenland, Susan Cowan and Steen Hoffman for access to unpublished data for Denmark, and Jessica Leston for her assistance accessing data for Alaska.

This research was supported in part by the University of Toronto and Montana State University.

Dr Gesink Law is an epidemiologist and assistant professor in the Department of Public Health Sciences at the University of Toronto. She has research interests in sexual, reproductive, and aboriginal health and, with Dr Rink, has been building a research program in sexual health and STIs with northern frontier and aboriginal communities in North America.

ReferencesArctic Climate Impact Assessment Impacts of a warming Arctic: Arctic climate impact assessment. New York: Cambridge University Press; 2004Gaydos CA, Kent CK, Rietmeijer CA, Willard NJ, Marrazzo JM, Chapin JB, Prevalence of Neisseria gonorrhoeae among men screened for Chlamydia trachomatis in four United States cities, 1999–2003.Sex Transm Dis 2006;33:3149 10.1097/01.olq.0000194572.51186.9616505744Levine SB, Coupey SM Adolescent substance use, sexual behavior, and metropolitan status: is “urban” a risk factor?J Adolesc Health 2003;32:3505 10.1016/S1054-139X(03)00016-812729984Adimora AA, Schoenbach VJ, Doherty IA HIV and African Americans in the southern United States: sexual networks and social context.Sex Transm Dis 2006;33(Suppl):S3945 10.1097/01.olq.0000228298.07826.6816794554Thomas JC From slavery to incarceration: social forces affecting the epidemiology of sexually transmitted diseases in the rural South.Sex Transm Dis 2006;33(Suppl):S610 10.1097/01.olq.0000221025.17158.2616794556Aral SO, O’Leary A, Baker C Sexually transmitted infections and HIV in the southern United States: an overview.Sex Transm Dis 2006;33(Suppl):S15 10.1097/01.olq.0000223249.04456.7616794550Farley TA Sexually transmitted diseases in the Southeastern United States: location, race, and social context.Sex Transm Dis 2006;33(Suppl):S5864 10.1097/01.olq.0000175378.20009.5a16432486Rhodes SD, Eng E, Hergenrather KC, Remnitz IM, Arceo R, Montaño J, Exploring Latino men’s HIV risk using community-based participatory research.Am J Health Behav 2007;31:1465817269905Johnson LF, Coetzee DJ, Dorrington RE Sentinel surveillance of sexually transmitted infections in South Africa: a review.Sex Transm Infect 2005;81:28793 10.1136/sti.2004.01390416061532Sangani P, Rutherford G, Wilkinson D Population-based interventions for reducing sexually transmitted infections, including HIV infection.Cochrane Database Syst Rev 2004;2:CD00122015106156Bjerregaard P, Mulvad G, Olsen J Studying health in Greenland: obligations and challenges.Int J Circumpolar Health 2003;62:51612725338Centers for Disease Control and Prevention Sexually transmitted disease surveillance, 2006. Atlanta: US Department of Health and Human Services; 2007Gessner BD, McLaughlin J, eds. Chlamydia trachomatis—Alaska, 2006 State of Alaska Epidemiology Bulletin. 2007 [cited 2007 Oct 25]. Available from http://www.epi.alaska.govPublic Health Agency of Canada STI data tables. Surveillance and Epidemiology Section, Community Acquired Infections Division, Centre for Infectious Disease Prevention and Control. 2007 [cited 2007 Oct 25]. Available from http://www.phac-aspc.gc.ca/std-mts/stddata_pre06_04/index_tab_e.htmOffice of the Chief Medical Officer in Greenland Ukiumoortumik Nalunaarut Årsberetning 2004. Nuuk, Greenland: Embedslægeinstitutionen i Grønland; 2005Office of the Chief Medical Officer in Greenland Ukiumoortumik Nalunaarut Årseberetning 2003. Nuuk, Greenland: Embedslægeinstitutionen i Grønland; 2004Orr PH, Brown R Incidence of ectopic pregnancy and sexually transmitted disease in the Canadian central Arctic.Int J Circumpolar Health 1998;57(Suppl 1):1273410093261Wong D, Swint E, Paisano EL, Cheek JE Indian Health surveillance report sexually transmitted diseases 2004. Atlanta: Centers for Disease Control and Prevention and Indian Health Services; 2006Kaufman CE, Shelby L, Mosure DJ, Marrazzo J, Wong D, de Ravello L, Within the hidden epidemic: sexually transmitted diseases and HIV/AIDS among American Indians and Alaska Natives.Sex Transm Dis 2007;34:7677717538516Steenbeek A, Tyndall M, Rothenberg R, Sheps S Determinants of sexually transmitted infections among Canadian Inuit adolescent populations.Public Health Nurs 2006;23:5314 10.1111/j.1525-1446.2006.00592.x17096778Larkin J, Flicker S, Koleszar-Green R, Mintz S, Dagnino M, Mitchell C HIV risk, systemic inequities, and Aboriginal youth: widening the circle for HIV prevention programming.Can J Public Health 2007;98:1798217626380Elwy AR, Hart GJ, Hawkes S, Petticrew M Effectiveness of interventions to prevent sexually transmitted infections and human immunodeficiency virus in heterosexual men: a systematic review.Arch Intern Med 2002;162:181830 10.1001/archinte.162.16.181812196079Nusbaum MR, Wallace RR, Slatt LM, Kondrad EC Sexually transmitted infections and increased risk of co-infection with human immunodeficiency virus.J Am Osteopath Assoc 2004;104:5273515653780Lapidus JA, Bertolli J, McGowan K, Sullivan P HIV-related risk behaviors, perceptions of risk, HIV testing, and exposure to prevention messages and methods among urban American Indians and Alaska Natives.AIDS Educ Prev 2006;18:54659 10.1521/aeap.2006.18.6.54617166080Hellerstedt WL, Peterson-Hickey M, Rhodes KL, Garwick A Environmental, social, and personal correlates of having ever had sexual intercourse among American Indian youths.Am J Public Health 2006;96:222834 10.2105/AJPH.2004.05345417077401Holkup PA, Tripp-Reimer T, Salois EM, Weinert C Community-based participatory research: an approach to intervention research with a Native American community.ANS Adv Nurs Sci 2004;27:1627515455579Smith A, Christopher S, McCormick AK Development and implementation of a culturally sensitive cervical health survey: a community-based participatory approach.Women Health 2004;40:6786 10.1300/J013v40n02_0515778139Mail PD, Conner J, Conner CN New collaborations with native Americans in the conduct of community research.Health Educ Behav 2006;33:14853 10.1177/109019810427205416596762Whitbeck LB, Adams G, Hoyt D, Chen X Conceptualizing and measuring historical trauma among American Indian people.Am J Community Psychol 2004;33:11930 10.1023/B:AJCP.0000027000.77357.3115212173Jervis L, Beals J, Croy C, Klein S, Manson S Historical consciousness among two American Indian tribes.Am Behav Sci 2006;50:52649 10.1177/0002764206294053Quigley D A review of improved ethical practices in environmental and public health research: case examples for native communities.Health Educ Behav 2006;33:13047 10.1177/109019810427205316531510Whitbeck L Some guiding assumptions and a theoretical model for developing culturally specific preventions with Native American people.J Community Psychol 2006;34:18392 10.1002/jcop.20094