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Syphilis is caused by bacteria and is contagious in the early stages of transmission. Without treatment, it can cause irreversible damage to the brain, nerves and body tissues. 

Signs and Symptoms

Each stage of Syphilis has different symptoms, or none.

Primary Syphilis

Also known as ‘Stage One Syphilis’ has any one, or a multiple, of these symptoms, OR NONE.

1. Very small pimple or tear in skin, with no tenderness or pain.
2. Painless spot on your tonsil.
3. A feeling like you have bitten your cheek.
4. A small tear in the skin (can be very small).
5. A sore with raised edges, small or up to two centimetres wide.
6. Spots on body that appear like a small sweat rash, not itchy.
7. A shiny, glossy or mucousy patch on the skin that may resemble an ulcer.
8. Something that looks like a wart, but goes away.
9. Something that looks like a herpes sore, but goes away and could be painless.

Primary Syphilis lasts for a few weeks, and symptoms can be painless or tender. For this reason, many people do not notice the symptoms. The symptoms go away after a few weeks. At this point, Secondary Syphilis develops.

Primary Syphilis can overlap with Secondary Syphilis for a few weeks.

Foetal transmission can occur during this time.

Secondary Syphilis

Also known as ‘Stage Two Syphilis’ has any one, or a multiple, of these symptoms, OR NONE.

Body rash, comes and goes

• Reddish or brownish or blotchy.
• Not itchy and not infectious.
• Can be on soles of feet and hands, or anywhere.
• The rash comes and goes, and can be small and not noticeable.

General feeling of being unwell, comes and goes

• Flu-like symptoms, but not infectious like a normal flu.
• Sore throat.
• Fatigue, generally feeling low energy .
• Swollen lymph nodes.
• Hair loss more than usual (not always noticeable).
• Symptoms come and go, appear to resolve on their own.

Condylomata Lata

During Secondary Syphilis the person can also develop something called ‘Condylomata Lata’. This is when the Syphilis bacteria starts to live within skin folds in the genital, mouth and anal regions. There are no clear symptoms of this condition; however, it comes with a lot of transmission risk because the bacteria is in concentrated amounts.

Secondary Syphilis can last for many years before developing into Tertiary Syphilis.

Tertiary Syphilis can overlap with Secondary Syphilis.

Latent Stage Syphilis

Possible during Stage Three Syphilis, and not everyone will develop this. No symptoms.

If left untreated, Secondary Syphilis may progress to the latent (hidden) phase. Not everyone who has Syphilis will go through this stage. For those who do, there won’t be any symptoms, maybe for years. In some cases, symptoms will never return. But the infection isn’t gone; the bacteria remain inactive in the body and will still show up in a test.

Transmission risks during the latent phase are much lower than during other stages. Foetal transmission can occur during this time.

Some latent cases may progress to the tertiary stage of the disease.

Not all people with latent Syphilis will develop Tertiary Syphilis.

Tertiary Syphilis

Note: Some people have no symptoms.

• Problems controlling muscle movements.
• Numbness.
• Vision problems (starting to go blind).
• Hearing problems (starting to go deaf).
• Dementia symptoms.
• Seizures, hallucinations, stroke, mental disturbance.
• Incontinence.
• Meningitis.
• Non-cancerous lesions on the skin, mouth and internal tissues.
• Inflammation of the aorta in the heart, this can cause aortic aneurysm.
• Aortic aneurysm—thinning of the lining of the aorta in the heart. If this bursts the person will likely die.

There is no risk of skin-to-skin transmission during Tertiary Syphilis.

Tertiary Syphilis is curable with diagnosis and treatment. But if it’s already had an effect on the body or organs, the damage may be irreversible. Even if treated, it may have permanently damaged the heart and brain.

Syphilis 101

What is Syphilis?

It’s a disease caused by the bacteria Treponema pallidum.

What causes Syphilis?

Syphilis is transmitted through human-to-human contact, when the genitals, anal area or mouth (i.e. mucous membranes) come into direct contact with the bacteria. This is how the bacteria enters the body.

Why should I be concerned about Syphilis?

It’s increasing all around Australia and likely you will have contact with it at some time.

How will I know if I have Syphilis?

The short answer is—you may have no symptoms, so your body might not tell you that you have Syphilis. The only way to know for sure is to get tested.

You should find out from the place you get your usual STI tests if they test for Syphilis. If not, ask for a test, and test regularly.

If you have had a condom slippage or breakage, you should get tested.

If you have seen a client with the above symptoms, you should get tested.

What if Syphilis isn’t treated? What happens without treatment?

Syphilis will become a complicated health problem if untreated. The long-term impact of Tertiary Syphilis on the heart and brain cannot be reversed.

Transmission

How’s Syphilis passed on?

Activity that does not transmit Syphilis:

• Touching something it has touched.
• Touching a person’s blood with the hands, or anywhere on the skin.

Activity that does transmit Syphilis:

• General sexual activity that means your genitals, anal area or mouth come into contact with Syphilis.
• Rubbing and skin-to-skin contact that involves genitals, anal area and/or mouth.
• Uncovered oral sex.
• Covered oral sex, if the mouth touches an area that has Syphilis on it.
• Genital contact.
• Touching a Syphilis sore with your fingers then touching a mucous membrane (such as your eyes, inside of your nose or mouth, or your genitals).
• It’s also passed on during pregnancy and birth of the baby.

Kissing, oral and blow jobs

• Syphilis enters the body through mucous membranes.
• Mouth, genitals and anal regions are mucous membranes.
• Sharing saliva without direct contact with a Syphilis symptom inside another person’s mouth is not considered risky.

AND

• Genital-to-oral contact when a Syphilis symptom is present inside the mouth or on genitals does transmit Syphilis.

The research on this is confusing.

Blood-to-blood contact

While very rare, Syphilis transmission can happen as a result of blood-to-blood contact. Sexual transmission remains the most common way that Syphilis is passed on.

Blood-to-blood transmission of Syphilis can happen when sharing injecting equipment.

If blood comes into contact with an open, bleeding wound transmission can occur. For example, blood having contact with an open mouth ulcer or bleeding gums. However, there are very limited cases of people contracting Syphilis through blood-to-blood contact.

Testing 

Why do I have to ask for a test?

The doctor may not offer a test.

A Syphilis test is not always included in a standard STI screen.

In Australia, STI testing is decided by your GP or clinic based on their routine and the symptoms you have. However, your usual doctor may not be familiar with Syphilis symptoms—which is why they might not offer you a test. A sexual health clinic also may not pick up the signs.

It is worth asking for a Syphilis test regularly, and/or making sure that the STI screen the person is receiving includes a test for Syphilis. If they don’t ask, they may not be tested for Syphilis. It takes up to three weeks after infection for Syphilis to show up in a test.

How to know which Syphilis test to ask for?

A doctor or clinic may not understand the different tests for Syphilis. The person who is requesting a test can ask what type of Syphilis test the doctor or clinic is going to do.

To request the type of test that is right for you, you will need to understand the different tests.

Antibody test

• Blood test.
• To see if the person has ever been exposed to Syphilis.
• This test will not detect what stage of Syphilis the person has.

If there is a reactive (positive) result, the blood sample is tested twice in the lab to be sure of the result.

Note: If someone has ever had Syphilis before, even if it was treated and is now inactive, Syphilis will still show up on the antibody test. In this case, the antibody test does not indicate a current case of Syphilis that needs treatment. Only the PCR or RPR tests (explained next) can confirm this.

Polymerase Chain Reaction test (PCR test)

• Skin swab of Primary Syphilis symptoms.
• This test will not detect what stage of Syphilis the person has.
• This test detects if the person has an active case of Syphilis.

Rapid Plasma Reagin test (RPR test)

• Blood test.
• This test detects if someone has an active case, AND what stage of Syphilis they have.
• This test is done in a lab, by hand.
• Treatment decisions are sometimes based on the RPR test.

If a person has ever had Syphilis before, and been treated, the RPR test is a method to detect if the person has been re-infected.

This is why it is very important to tell the clinic about previous Syphilis infections and treatment.

Point of Care Rapid Test for Syphilis

• Finger prick blood test.
• This test can only determine if you have ever been exposed to Syphilis. Point of Care Rapid Tests must be done in combination with traditional Syphilis blood testing to confirm that the infection is current.
• Point of Care Rapid Tests are available to priority populations, such as Aboriginal and Torres Strait Islander peoples, injecting drug users and men who have sex with men, at some sexual health clinics. Sex work status alone may not necessarily make you eligible for Point of Care Rapid testing for Syphilis.

Treatment 

Types of treatment

Treatment for Syphilis is delivered by a needle or two in the butt cheek or the side of the hip, by the doctor or a nurse at a clinic. A single dose will cure early Syphilis, but later stages require 3 injections, each a week apart.

It is a painful procedure. It does not require admission to hospital, it is done in a clinic. The treatment is a drug called Penicillin G benzathine.

If the person is allergic to penicillin, or is unable to be injected, they will receive Doxycycline as an oral treatment for 14 or 28 days, depending on what stage of Syphilis they have. It is two pills per day.

After the first treatment, the person will be tested again 3 months later, and then usually 6 months and 12 months after treatment. The doctor or clinic will advise and make the follow-up appointments with the patient.

It is very important to attend within the suggested time frames in order for the infection to resolve 100% and not risk it remaining active in the body.

How effective is the treatment?

Penicillin G benzathine is proven to be effective at killing Treponema pallidum, the bacterium that causes Syphilis.

For people allergic to penicillin, there is an alternative called Doxycycline. It is effective, but there is less evidence of success than with use of Penicillin G benzathine.

Any side effects?

It’s painful and some people report that it hurts to sit down for a day or two after the injections.

Some people report feeling sick after the treatment, and may have a fever, chills, headache and/or muscle pain. This can last a few hours and then goes away by itself. It is due to the dead bacteria in the body.

I’ve had Syphilis, now what?

• Being infected or treated does not equal immunity.
• Syphilis can be caught again after treatment.
• Having it previously does not mean the person is at higher risk.
• Having it previously does mean an antibody test (blood test) will always show up positive. This does not mean the person currently has an active case. The person would need to have a PCR or RPR test prior to determine if they have an active case and if treatment is required.

If a person has ever had Syphilis before, they need to tell the GP or clinic that they require an RPR test.

Current demographics & statistics

Syphilis is not high among sex workers. But we suggest, based on the available evidence, that our clients are the people more likely to be living with Syphilis and not realise. That is why we are educating ourselves and our clients about Syphilis now.

Cairns Sexual Health has noticed that the most common cases of Syphilis are occurring in these groups of people:

• FIFO workers
• Cis-men
• Heterosexual people

Prevention at work

• Visual STI check of clients before the booking goes ahead. Use a light and gloves if possible.
• Wash your hands after the check if you don’t use gloves.
• Wash your hands after wanking and before touching your own genitals.
• Recent studies show that antibacterial soap is no more effective at reducing bacterial levels than regular soap (Aiello, Larson & Levy, 2007; Giuliano & Rybak, 2015; Kim & Rhee, 2016). Also, antibacterial soap is no more effective at reducing disease incidence on a community level than non-antibacterial soap (Luby et al, 2005). Normal soap is good enough.
• Put a bandaid on anything that looks like a symptom of Primary Syphilis.
• Cover symptoms of Primary Syphilis with a towel.
• Reconsider deep kissing.
• Do face-down body rubs and body slides to avoid genital contact with symptoms of Primary Syphilis.
• Reduce contact between genitals.
• Cover toys with condoms, wash and re-cover prior to using on yourself.
• Do covered oral, and search for Syphilis symptoms outside of the area covered by a condom or dam.
• Keep in mind that symptoms are usually not obvious. Using condoms and dams during genital contact is always a good prevention method.

Syphilis and pregnancy

Syphilis screening in Australia is now standard for all pregnancies.

• If untreated, Syphilis may lead to stillbirth.
• If untreated, the child may be born with Syphilis.
• Syphilis usually kills the child very soon after birth (8 deaths of babies in Australia related to Syphilis so far).

Treating the birthing parent during pregnancy can prevent complications and/or transmission to the unborn child. Testing and treatment will make sure the baby is healthy and safe.

Call to action: Educating peers, clients and yourself

We recognise that sex workers as a community play a key role in educating clients and peers on Syphilis, as well as becoming experts with the latest Syphilis information. 

Part of our work practice includes talking to clients with confidence about sexual health.

• Try to make Syphilis conversations sexy and focused on safety.
• ‘I care about your health, let’s keep the booking safe for both of us’.
• Encourage clients and co-workers to get tested.
• We will play a leading role in curbing the epidemic.
• Clients may want to know about possible STI symptoms more than you’d think. They trust us and often don’t talk to anyone else about sex (Robinson and Mawulisa 2003).
• Are you now an expert? If you have read this resource the answer is YES! Share your knowledge with others.
• Are you using the prevention methods already? Most likely YES. Share your experience-based Syphilis prevention methods with other sex workers. They will appreciate the ideas.

Each state and territory has different laws regarding working with an STI. Some states have made it illegal to work while you have an STI, even if you are using safer sex practices or offering services that do not have a risk of transmission. If you test positive for Syphilis, it is recommended that you contact your local sex worker organisation to understand how the laws in your state or territory impact you and your rights and responsibilities.

For more information on STIs and the law, see:

• The Scarlet Alliance State by State Laws in Australia.
• The Redbook’s STIs, BBVs, and the Law.
• Respect Inc’s Sex Work and the Laws in Queensland.
• SWOP NSW information on the Public Health Act in NSW.

If you are charged with a sex work and BBV or STI-related offence, contact Scarlet Alliance for referrals to legal assistance.

Putting your sexual and mental health first

How do I combat fear about Syphilis?

• Get tested and be aware of your Syphilis status.
• Syphilis is going around—it is now part of our everyday conversation and business practices.
• It could be around for a while. Learning about it is the best way to combat fear.

Many of us fear we are not doing the STI visual screening on clients properly.

Most sex workers are not currently familiar with Syphilis. It’s easy to overlook or ignore the symptoms of Primary Syphilis. Basically, it is hard to determine whether it is a symptom, or just a small cut or skin tag. Play it safe by using bandaids, washing hands, using towels and doing face-down massage and/or body slides. Sex workers are actually the only people using an STI visual screen—keep at it and you will gain confidence.

Fear of losing clients if we do the STI visual screen.

Many of us are fearful we might lose a client if we do the visual screen and find a symptom. We get worried about unnecessary arguments and loss of income. In this stage, smooth communication skills are needed. Make the client comfortable. It can help to discuss the reasons behind it: ‘I do this with everyone, it’s no big deal.’, ‘Let’s get this out of the way so we can relax and have fun’.

Fear that a client has given us Syphilis.

The easiest way to overcome this fear is to go for a test. Then you can relax your mind. Treatment in Australia is backed up with a re-test, and the clinic will make sure that treatment was successful, or they will re-treat until you are cleared.

Fear about telling clients to whom we have potentially passed Syphilis.

Fear of having transmitted Syphilis to a client can be really stressful. If you have a positive Syphilis result, the clinic contact tracing staff will want you to inform all of your recent sexual partners. It’s a big deal for us, as our health is our profession. ‘Will they out me on the reviews?’ ‘Will they tell other clients I’ve had Syphilis?’ ‘How will this impact my future income?’

Fear about Syphilis testing.

Stigma from health care professionals is unfortunately common.

Is there a sex worker-friendly clinic, LGBT-friendly clinic near you?

Fear about re-infection.

Just because you have had Syphilis before doesn’t mean you are at greater risk of having it again. The treatment does create stress about re-infection because you know first-hand how serious it is. Australia is having a Syphilis epidemic. Catching it twice can happen. Come back to this resource and have a look at what you can change about the way you work.

Should I tell my partners or clients I have Syphilis?

If you test positive for Syphilis you are going to be put in a situation where you will have to tell your recent sexual partners. This is stressful, and the fear of stigma is real. Discrimination occurs often. As sex workers, our health is our asset. Drop into your local sex worker organisation, talk with co-workers, use stress management techniques. It will be hard but you can do it.

How soon can I have sex again?

Coming back to work is important for sex workers.

However, if you have tested positive for Syphilis, it is advised that you should wait at least seven days after completing your treatment and all signs and symptoms of Syphilis have cleared before continuing sexual activity.

References

• Aiello A, Larson E, & Levy S. Consumer Antibacterial Soaps: Effective or Just Risky?. Clinical Infectious Diseases. 2007; 45(Supplement 2), S137–S147. http://dx.doi.org/10.1086/519255
• Giuliano C & Rybak M. Efficacy of Triclosan as an Antimicrobial Hand Soap and Its Potential Impact on Antimicrobial Resistance: A Focused Review. Pharmacotherapy: The Journal Of Human Pharmacology And Drug Therapy. 2015; 35(3), 328–336. http://dx.doi.org/10.1002/phar.1553
• Kim S & Rhee M. Microbicidal Effects of Plain Soap vs Triclocarban-based Antibacterial Soap. Journal Of Hospital Infection. 2016; 94(3), 276–280. pmid:27585555
• Luby S, Agboatwalla M, Feikin D, Painter J, Billhimer W, Altaf A, et al. Effect of Handwashing on Child Health: A Randomised Controlled Trial. The Lancet. 2005; 366(9481), 225–233. http://dx.doi.org/10.1016/s0140-6736(05)66912-7
• Robinson K, Mawulisa S. Sex Workers as Educators. HIV Australia. V3, #1, Sept–Nov 2003. http://www.scarletalliance.org.au/issues/peereducation/mawulisa_robinson03