Sexually transmitted diseases are getting worse in the United States, increasing for the third year, with 2016 reaching an all-time high.

According to the Centers for Disease Control and data analysis by Backgroundchecks.org, here are the ten most sexually diseased states in America:

Alaska Mississippi Louisiana Georgia New Mexico North Carolina South Carolina Arkansas Delaware Oklahoma

The ten least sexually diseased states are:

Vermont New Hampshire West Virginia Maine Utah Idaho Wyoming Connecticut Massachusetts New Jersey

The state moving up the highest in the rankings [as most diseased] is Maryland, jumping up six spots from #24 to #18, owing to significantly elevated rates of both gonorrhea and chlamydia. Next is Delaware, climbing five spots from #14 to #9. There is a four-way tie between Georgia (#4), Indiana (#23), Virginia (#25) and North Dakota (#26) for third greatest increase as they all moved up three places in the rankings. Hawaii experienced the greatest drop in the rankings, falling eight spots from #20 to #28 due to a decrease in the chlamydia rate per 100k residents. Three states–Texas (#16), Tennessee (#22), and Michigan (#27)–fell four spots each, while three others–North Carolina (#6), Colorado (#30), Vermont (#50)–went down three spots.

STDs in all categories have seen an increase:

Chlamydia: 4.7 percent rate increase since 2015

Gonorrhea: 18.5 percent rate increase since 2015

Primary and Secondary Syphilis: 17.6 percent rate increase since 2015

Congenital Syphilis: 27.6 percent rate increase since 2015

“Increases in STDs are a clear warning of a growing threat,” said Dr. Jonathan Mermin, director of CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “STDs are a persistent enemy, growing in number, and outpacing our ability to respond.”

The rise in primary and secondary syphilis over the last 17 years is primarily attributable to increases among men, specifically homosexuals.

“In 2016, men accounted for almost 90% of all cases of P&S syphilis,” the report says. “Of those male cases for whom sex of sex partner was known, 80.6% were men who have sex with men. … half of men who have sex with men diagnosed with syphilis were also living with HIV.”

The same is true with gonorrhea:

“While gonorrhea increased among men and women in 2016, the steepest increases were seen among men (22 percent). Research suggests that a large share of new gonorrhea cases are occurring among MSM [men who have sex with men]. These trends are particularly alarming in light of the growing threat of drug resistance to the last remaining recommended gonorrhea treatment.”

Other reasons attributed to the increase in STDs in America are poverty, lack of sex education, low-quality health care, and the hook-up culture. I decided to look at these statistics and see if these are truly the causes. What I found was a little surprising.

First of all, you would think that most sexually active states would be on the list for the most sexually diseased. Not so. Of the top ten states where people are having the most sex, none of them are in the top ten of states that are most diseased. The most sexually active states are

California Texas New York Oregon Colorado Arizona Washington Massachusetts Connecticut Missouri

These are just general comparisons, but since no sexually robust state is in the top ten diseased states, maybe there are other more significant factors, such as sex education. We often hear that states with abstinence-only sex education put people at greater risk, but I found that of the eleven states with abstinence-only education, only three are on the most sexually diseased list: Arkansas, Louisiana, and Mississippi.

Lack of quality health care seems to be a greater factor since seven out of the top ten worst states for health care are also on the worst STD list: Louisiana, Mississippi, Alaska, Arkansas, North Carolina, Georgia, and South Carolina.

Another reason listed for high STD rates is poverty. This certainly seems to be a factor because none of the richest states are on the most diseased list while six of the top ten poorest states are riddled with STDs: Mississippi, Arkansas, New Mexico, Louisiana, South Carolina, and North Carolina.

The CDC report on STDs in America says poverty especially impacts the black community since the poverty rate in 2015 for whites was 9.1 percent and for blacks it was 24 percent. The STD statistics seem to correlate with race since the percentage of blacks with STDs is higher in every disease category than whites. It’s also reported that blacks have more sex than whites.

According to the CDC’s report on minorities and STDs,

The rate of reported chlamydia cases among Black women was 5.1 times the rate among White women (1,387.2 and 271.1 cases per 100,000 females, respectively). The rate of reported chlamydia cases among Black men was 6.6 times the rate among White men (839.0 and 126.4 cases per 100,000 males, respectively). In 2016, 51.0% of reported gonorrhea cases with known race and ethnicity occurred among Blacks (excluding cases with missing information on race or ethnicity, and cases whose reported race or ethnicity was Other). The rate of reported gonorrhea cases among Blacks in 2016 (481.2 cases per 100,000 population) was 8.6 times the rate among Whites (55.7 cases per 100,000 population). The rate of reported [primary and secondary] syphilis cases among Blacks in 2016 (23.1 cases per 100,000 population) was 4.7 times the rate among Whites (4.9 cases per 100,000 population). The disparity was higher for Black women (7.0 times the rate among White women) than for Black men (4.6 times the rate among White men).

These higher STD rates among blacks compared to whites also correlate with states that are most heavily populated with blacks. Of the top ten states that have high numbers of blacks, six are listed as having high STD rates. These include Mississippi, Louisiana, Georgia, South Carolina, Delaware, and North Carolina.

Of the states mostly populated by whites, none are on the most diseased list, though two states are among the most poor: West Virginia and Kentucky. Of the states with the least STDs, six are mostly white: Vermont, New Hampshire, West Virginia, Maine, Idaho, and Wyoming.

“Race and Hispanic ethnicity in the United States are population characteristics that are correlated with other factors affecting health status such as unemployment and low educational attainment,” the CDC report says. “Those who cannot afford basic life necessities often have trouble accessing and affording quality sexual health services. People who struggle financially are often experiencing life circumstances that potentially increase their risk for STDs.”

An interesting caveat to this that I found, however, is that if increased rates of STDs are attributable to poverty, then one would assume that the rates of STDs would decrease as poverty decreases. This has not been the case. 2016 is the highest rate of STDs, having been on the increase in the last three years. But poverty among blacks has decreased.

The percentage of blacks living below the poverty level is the lowest it has been since 2000. It was 22 percent in 2016. In 2008, this percentage was 24.7, peaking in 2011 at 27.6. It remained about the same for a few years until it began to drop in 2015. Of course, the sexual behavior of individuals might need more time to catch up to the dropping poverty rates.

The CDC recognizes that there has been a stabilization of poverty rates in America, but the report says many Americans are still facing challenges “overcoming inequalities in economic opportunity.” The CDC says” health care disparity” is a factor since “many people in the United States continue to lack access to health care.”

Even when health care is available, fear and distrust of health care institutions can negatively affect the health care-seeking experience for many racial/ethnic minorities when there is social discrimination, provider bias, or the perception that these may exist. Moreover, the quality of care can differ substantially for minority patients. Inequities in social and economic conditions are reflected in the profound disparities observed in the incidence of STDs among some racial and ethnic minorities. In communities where STD prevalence is higher because of these factors, persons can experience difficulties reducing their risk for sexually transmitted infections. With each sexual encounter, they can face a greater chance of encountering an infected partner than those in lower prevalence settings. Acknowledging inequities in STD rates by race or ethnicity is one of the first steps in empowering affected communities to organize and focus on this problem.

The solutions to the increase in STDs suggested by the CDC include state and local health departments focusing on detecting STDs earlier and treating those in need; health care providers making STD screening part of standard treatment of care as prevention; and everyone talking openly about STDS: “get tested regularly, and reduce risk by using condoms or practicing mutual monogamy if sexually active.”

This last point is one you don’t hear often from the government, and in my opinion, it should be listed first before anything else.