In 2013, condom manufacturer Sagami conducted a national survey on sex that seemed to confirm suspicions that there is relatively little sex being had in Japan. According to the survey, adults in Japan have sex between 17 to 45 times a year on average. In comparison, the Chinese have sex 96 times a year while the Greeks do it 138 times a year — more than reported by any other nationality. Nevertheless, the same set of surveys also indicates that 83 percent of single men and 58 percent of single women in their 20s and 30s in Japan would like to have more sex. This notable discrepancy may explain why approximately 40 percent of all Japanese men pay for sex, why there’s been a recent uptake in females visiting male host bars and the general increase in the use of internet-assisted dating for casual hookups across all sexual preferences.
And where there is sex, there are sexually transmitted infections (STIs). In January 2017, the Japanese Ministry of Health (MoH) launched a special research team to find ways of curbing an unprecedented increase in reported cases of STIs, especially syphilis. Syphilis is one of the oldest documented diseases spread primarily by sexual activity that, if left untreated, can cause serious vascular and neurological damage even many years after the initial infection. Once infected, there may be symptoms such as fever and discomfort but often patients show no signs of infection, making it difficult for doctors to diagnose. If a pregnant woman is infected with syphilis, it may result in a miscarriage, stillbirth, or congenital syphilis, meaning the infant is born with the disease.
In 2016, Yoshiyuki Sugishita of the Tokyo Metropolitan Institute of Public Health led a study in Tokyo that showed the number of confirmed cases of syphilis in Tokyo per year had doubled from 108 in 2007 to 245 in 2013 — largely amongst men aged from 20 to 49. The primary route of infection was male-to-male transmission, and men who have sex with men (MSM) accounted for nearly 80 percent of male cases in 2013. The very latest studies show that in the first six months of 2017 alone, there were over 650 confirmed cases of syphilis in Tokyo. In this period, men of all age groups (MSM and heterosexual) as well as women in their 20s accounted for the majority of the cases.
In the same study, the researchers suggest that the increase in STI rates amongst MSM may be due to an attitude that HIV prevention tools or counseling services have become tiresome; HIV is no longer viewed a “death sentence” but rather a manageable chronic illness owing to improved antiretroviral therapies. Prevention fatigue and treatment optimism have been linked with an increase in recreational drug use, which in turn is associated with risky sexual behavior and hence a higher risk of unprotected sex. These are worrying causal trends given that approximately 15 percent of people living with HIV/AIDS in Japan remain undiagnosed and may be infecting their partners unknowingly.
Every ward in Tokyo offers some form of free and anonymous STI testing services at their hokenjo (public health center). However, opening hours are restricted and results take a week to be released, which deters many people from getting tested. STI home tests are also an option. However, there is no viable system in place to ensure those who tested positive for STIs are referred for treatment and counseling. During the month of June 2017, Tokyo Metropolitan Government increased the number of free HIV/STI screening and counseling sessions at public health centers across Tokyo. They hope to improve early detection of HIV and other STIs whilst the MoH research team continue to work on finding the underlying causes for the current epidemic, one of which may be the shifting attitudes towards sex and STIs in Japan.
The Japanese National Institute of Infectious Diseases (NIID) is keen to investigate the link between risky sexual behavior and internet-assisted dating. This seems unnecessary as there is sufficient international research to support that internet-assisted dating (via apps like Tinder, Pairs, Jack’d, Ashley Madison) is associated with an increased likelihood to engage in sex without protection, have concurrent partnerships and a higher number of partners. It is important to note that association is different from causation — there is no research to support that dating apps caused this shift in people’s attitudes towards sex and their behaviors. Rather, they make sexual encounters more accessible. According to the extramarital affair dating website Ashley Madison, 55 percent of Japanese women using the service said they were doing so because they weren’t having enough sex in their marriage. The Sagami survey results reveal that even when Japanese adults engage in sexual activities, regardless of age, the level of satisfaction is low.
Professor Kaku Sechiyama at the University of Tokyo suggests that the combination of a sexually-dissatisfied group with the very limited percentage of people who are open-minded about sex but not able to convey their desires to their partners means a higher susceptibility to extremes, such as abstinence or affairs. That would also explain the ever-increasing “market for grown-ups,” i.e. the ¥4 trillion (and rising) Japanese sex industry. Nevertheless, the increase in the number of STI cases in Japan can also be attributed to progressive public awareness activities encouraging more people to get tested. The MoH made Sailor Moon’s Usagi Tsukino the face of their STI awareness campaign, which targeted youth as well as, inadvertently, the LGBT community, who have been debating the sexual orientation of the character for years.
Given the data available, a potential public health priority for Tokyo would be reducing the risk of acquiring STIs — especially syphilis — among men who have sex with men, particularly in the 20 to 49 age group. The government currently has free and anonymous sexual health clinics near known cruising areas (such as Shinjuku-ni-chome) and may wish to consider the following to improve uptake: introduction of rapid HIV tests (providing results in 1 minute rather than 1 week), rapid-combination HIV/syphilis tests, and providing targeted counseling and free condoms. Looking at STI/HIV prevention practices around the world, the most successful campaigns are those whereby awareness is coupled with screening at venues frequented by high-risk groups such as clubs, saunas and (host/hostess) bars. The key outcomes of such campaigns include progressing early detection as well as reducing the stigma surrounding minority sexual orientations, improving health-seeking behavior and increasing partner notification.
Another key factor in successful STI/HIV prevention is devising appropriate messaging at women’s health clinics regarding sex and protection. There was a time when nearly 93 percent of the sexually-active youth in Japan believed the use of condoms was purely for preventing unwanted pregnancies. This may have exacerbated the false belief that the withdrawal method alone is sufficient protection. Healthcare professionals play an important role in this respect and the government may wish to start providing tailored training to them regarding how to approach their patients to discuss sex and sexual behavior. This may also have a positive impact on any prevailing sexual gender bias. Public awareness campaigns to consider comprise those that focus on positive safe-sex messaging and reducing the stigma of seeking contraceptives, screening and treatment. A key consideration is ensuring any STI/HIV campaigns occur where the action is taking place — for example, within popular dating apps and the blossoming sex industry. Tackling a yet-to-be-defined STI/HIV epidemic is challenging, and Japan may wish to examine the benefits of moving away from traditional institutionalized healthcare settings to more community-based accessible safe spaces, both online and offline.