If patients return to Dr. Crystal Bowe soon after taking medication for a sexually transmitted infection, she usually knows the reason: Their partners have re-infected them.
"While you tell people not to have sex until both folks are treated, they just don't wait," she said. "So they are passing the infection back and forth."
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That's when Bowe, who practices on both sides of the North and South Carolina border, does something doctors are often reluctant to do: She prescribes the partners antibiotics without meeting them.
Federal health officials have recommended this practice, known as expedited partner therapy, for chlamydia and gonorrhea since 2006. It allows doctors to prescribe medication to their patients' partners without examining them. The idea is to prevent the kind of reinfections described by Bowe -- and stop the transmission of STDs to others.
However, many physicians aren't taking the federal government's advice because of entrenched ethical and legal concerns.
"Health care providers have a long tradition of being hesitant to prescribe to people they haven't seen," said Edward Hook, professor at the University of Alabama's medical school in Birmingham. "There is a certain skepticism."
A nationwide surge of sexually transmitted diseases in recent years, however, has created a sense of urgency for doctors to embrace the practice. STD rates have hit an all-time high, according to the Centers for Diseases Control and Prevention. In 2017, the rate of reported gonorrhea cases increased nearly 19 percent from a year earlier to 555,608. The rate of chlamydia cases rose almost 7 percent to 1.7 million.
"STDs are everywhere," said Dr. Cornelius Jamison, a lecturer at the University of Michigan Medical School. "We have to figure out how to ... prevent the spread of these infections. And it's necessary to be able to treat multiple people at once."
A majority of states allow expedited partner therapy. Two states -- South Carolina and Kentucky -- prohibit it, and six others plus Puerto Rico lack clear guidance for physicians.
A 2014 study showed that patients were as much as 29 percent less likely to be re-infected when their physicians prescribed medication to their partners. The study also showed that partners who got those prescriptions were more likely to take the drugs than ones who were simply referred to a doctor.
Yet only about half of providers reported ever having prescribed drugs to the partners of patients with chlamydia, and only 10 percent said they always did so, according to a different study. Chlamydia rates were higher in states with no law explicitly allowing partner prescriptions, research published earlier this year showed.
Because of increasing antibiotic resistance to gonorrhea, the CDC no longer recommends oral antibiotics alone for the infection. But if patients' partners can't go in for the recommended treatment, which includes an injection, the CDC said that oral antibiotics by themselves are better than no treatment at all.
"Increasing resistance plus increasing disease rates is a recipe for disaster," said David Harvey, executive director of the National Coalition of STD Directors. The partner treatment is important for "combatting the rising rates of gonorrhea in the U.S. before it's too late."
The CDC recommendations are primarily for heterosexual partners because there is less data on the effectiveness of partner treatment in men who sleep with men, and because of concern about HIV risk.
Bowe said that even though she writes STD prescriptions for her patients' partners, she still worries about doing it because of possible drug allergies or side effects.
"I don't know their medical conditions," she said. "I may contribute to a problem down the road that I'm going to be held liable for."
In many cases, doctors and patients simply do not know about partner therapy. Ulysses Rico, who lives in Coachella, Calif., said he contracted gonorrhea several years ago and was treated by his doctor. He didn't know at the time that he could have requested medicine for his girlfriend. She was reluctant to go to her doctor and instead got the required antibiotics through a friend who worked at a hospital.
"It would have been so much easier to handle the situation for both of us at the [same] moment," Rico said.
Several medical associations support partner treatment. But they acknowledge the ethical issues, saying it should be used only if the partners are unable or unwilling to come in for care.
Federal officials are trying to raise awareness of the practice by training doctors and other medical professionals, said Laura Bachmann, chief medical officer of the CDC's office of STD prevention. The agency posts a map with details about the practice in each state.
Over the past several years, advocates have won battles state-by-state to get partner treatment approved, but implementation is challenging and varies widely, said Harvey, whose National Coalition of STD Directors is a member organization that works to eliminate sexually transmitted diseases.
The fact that some states don't allow it, or haven't set clear guidelines for physicians, also creates confusion -- and disparities across state lines.
The Planned Parenthood affiliate that serves both Indiana and Kentucky sees this firsthand, said clinical services director Emilie Theis. In Indiana, providers can legally write prescriptions for their patients' partners, but they are prohibited from doing so in Kentucky, even though the clinics are only a short drive apart, she noted. A similar dynamic is at play along the South Carolina-North Carolina border, where Bowe practices.
California started allowing partner treatment for chlamydia in 2001 and for gonorrhea in 2007. The state gives medication to certain safety-net clinics, a program it expanded three years ago. However, "it has been an incredibly difficult sell" because many medical providers think "it's a little bit outside of the traditional practice of medicine," said Heidi Bauer, chief of the STD control branch of California's public health department.
At APLA Health, which runs several health clinics in the Los Angeles area, nurse practitioner Karla Taborga occasionally gives antibiotics to patients for their partners. But she tries to get the partners into the clinic first, because she worries they might also be at risk for other sexually transmitted infections.
"If we are just treating for chlamydia, we could be missing gonorrhea, syphilis or, God forbid, HIV," Taborga said. But if prescribing the drugs without seeing the patients is the only way to treat them, she said, "it's better than nothing."
Edith Torres, a Los Angeles resident, said she pressured her then-husband to go to the doctor after he gave her chlamydia several years ago: She refused to have sex with him until he did. Torres said she wanted him to hear directly from the doctor about the risks of STDs and how they are transmitted.
If he had taken the medication without a doctor visit, he wouldn't have learned those things, she said. "I was scared and I didn't want to get it again."