Teaching your patients: Lessons that may help her avoid STIs

Recent findings reveal a number of important aspects of STI counseling that clinicians can use to identify at-risk patients and effect positive changes

By Jane Dimmitt Champion, PhD

Acquiring a sexually transmitted infection (STI) is the result of a complex interplay of culture, gender-roles, relationship dynamics, specific sexual behaviour and biological infection. Interventions to change the behaviour that leads to infection should address each of these aspects in ways that are understandable and relevant to the patients who are at risk, and should take place at clinics, hospitals, and schools.

Evidence from randomized, controlled trials shows behavioural interventions patterned after this approach are effective. Project Sexual Awareness for Everyone (S.A.F.E.), an intervention developed for African-American and Hispanic women was among the first such initiatives that significantly reduced the spread of new STIs (Shain 1999). Over the course of the yearlong study, 16.8% of the women in the study group became infected with a new STI, compared with 26.9% in the control group who received no intervention.

Improving the quality and effectiveness of interventions involves evaluating the approaches that are successful in changing risky behaviour, and determining what commonalities exist among women for whom they fail (Shain 2002). The findings of this study reveal a number of important aspects of STI counseling that clinicians can use to identify at-risk patients. They also provide critical information to help develop additional population-specific, public health interventions and culturally relevant counseling strategies.

Interventions and women with history of abuse

Women with history of mental, sexual or physical abuse have shown a lack of positive changes from interventions in past studies. Such women likely began having sexual intercourse at a younger age, have more partners, use drugs, and have more STIs than women who have not been abused (Champion 2001a). Young women who show any signs of being abused should be provided with very specific STI counseling as early as ages 9 to 12 years. Important risk markers for a history of abuse include frequent visits for complaints of pelvic pain, diagnosis of pelvic inflammatory disease, and having been under child protective services. (Champion, West J Nurs Res. 2004; Champion, J Am Acad Nurse Pract 2005). 

Modifying these five behaviours in high risk women, identified in the S.A.F.E. program, can help reduce infection rates (Shain 2002):

1. Refraining from sex with an untreated partner, 
2. lack of mutual monogamy, 
3. having unsafe sex, 
4. rapid partner turnover, and 
5. douching after sex

Researchers found that education about the risk of future infertility caused by STIs is a powerful deterrent to high risk behaviour. (Jensen 2006)

Lessons from the interventions

Reduced infection rates are the result of continuing to engage in low-risk behaviours while changing those that are high-risk. It may not be possible in a clinical setting to delve into the complex social dynamics that put a woman at risk for an STI. But by talking to her about the behaviours that are most likely to lower her risk, clinicians may help her prevent one.

Sex with untreated partners:

Women who have unprotected sex with an untreated or incompletely treated partner are 5.6 times more likely than women without this risk factor to acquire an STI during a year of S.A.F.E. analysis (Shain 2002). This logic may not be clear to all patients—some misunderstand what it means to avoid sex with untreated partners. Women should be told that both partners need to be tested, treated, and have a test of cure after treatment. Counseling should include the importance of screening sex partners and reminders that anyone could be infected without showing symptoms.

Mutual monogamy:

Women in nonmonogamous relationships have a cumulative infection rate of 31.4%, compared with a rate of 8.4% among the monogamous women (Shain 2002). Many women will readily discuss relationships, even in a clinical setting, and this can be an opportunity to talk about the reasons why a woman may tolerate a partner’s risky behaviours. Accepting poor behaviour may stem from low self-esteem, a desire to avoid conflict, the fear of losing the partner or violence, all of which should be addressed (Shain 1999). Raise the possibilities of convincing a partner to change their high-risk behaviour or ending the relationship and acquiring a new faithful partner.

Unsafe sex:

Unsafe sex is defined as never using condoms with one or more casual partners, or five or more unprotected acts in the past three months combined withincorrect or problematic condom use. Practicing safe sex reduces infection rates in women, and is the factor that reduces STI rates the most for women in nonmonogamous relationships (from an infection rate of 31.4% to 23.0%).  Clinicians should make their primary focus to encourage existing positive behaviours and prevent a shift from safe to unsafe sex, and discuss strategies for responding to a partner who will not use a condom. Some counselors raise the question of whether refusal to use a condom is a form of interpersonal abuse. Helpful suggestions to patients may be ways they can confront barriers to condom use, incorporate condoms into foreplay, and overcome machismo objections.

Rapid partner turnover:

Having sex with a new partner within three months of another partner correlates with higher STI rates. The acquisition of a new partner does not appear to contribute to the infection rate, but the abstention interval between partners does. Abstaining for at least three months not only limits concurrent relationships, but also reduces the number of partners and the number of unprotected sexual encounters over time (Shain 2002).
 
Douching after sex:

Douching after sex corresponds with higher rates of infection. Studies have found that douching significantly increases the likelihood of becoming infected with Chlamydia, gonorrhea and bacterial vaginosis (Shain 2002). Advise patients to avoid douching altogether and especially after sex, when it may facilitate the entry of pathogens into the endocervical canal.

Future fertility:

Women who are concerned about their future fertility are less likely to have multiple partners and concurrent relationships, and consequently have a lower STI risk profile (Jensen, 2006). After one year of behavioural intervention and STI education, women were more concerned about infertility caused by infection. Women in the intervention group—who became significantly more concerned than the control group (94.5% compared to 89.4%)—were educated about Chlamydia, gonorrhea, and trichomoniasis, their effects on the reproductive organs, and their potential to cause infertility in the future.

These results suggest that health professionals should advise women about the correlation between sexual behaviour and future fertility. Patients with an existing infection should be counseled that repeated infection could result in infertility. Unfortunately, infection risk and economic disadvantage often coincide, and many high-risk women lack resources for advanced fertility therapies and assisted reproduction techniques—helping them preserve their fertility becomes especially important.

Opportunities for counseling

Women with an STI or who are at risk can be a difficult population to reach, especially if they have a history of being abused. Many women delay seeing a health professional and often do not make appointments for preventive health care visits for a variety of reasons. These include lack of financial resources and insurance, difficulties with transportation, fear of violence, or their own embarrassment. For patients who fit any of these profiles, it is especially important to thoroughly investigate any complaints of pelvic pain, to use the opportunity to discuss STIs, and possibly give a referral to a community-based intervention program (Champion 2001,2004 and 2005 publications). A new opportunity to provide information about STIs to young women may be during vaccinations against the human papillomavirus.

Conclusion

Sexually transmitted infections that occur in the context of relationships are as much the result of particular behaviours as they are biologic outcomes. Altering a single behaviour may not impact reinfection rates, but modifying several behaviours together may. In the S.A.F.E. analysis, patients who practiced mutual monogamy and protected sex with an incompletely treated partner had the lowest rates of reinfection. Nonmonogomous women had lower reinfection rates when they incorporated avoiding sex with untreated partners and practiced safe sex or avoided rapid partner turnover. Study participants who did not practice these guidelines experienced infections rates over 50%. (Shain 2002)

Awareness of the risk factors for STIs and their symptoms is an important first step in the efforts of clinicians to address this health concern. Understanding the key behaviours that may reduce infection risk when they are modified will help clinicians educate their patients to optimize their own health. Recognizing that the effectiveness of community interventions is evidence-based can give clinicians confidence in referring their patients to these resources.

References

• Champion, J.D., Shain, R.N., Piper, J.M. (2004)  Minority adolescent women with sexually transmitted diseases and a history of physical or sexual abuse.  Issues in Mental Health Nursing, 23, 293-316.
• Champion, J.D., Shain, R., Piper, J., Perdue, S. (2001a) Sexual risk behaviours and woman abuse among minority women with sexually transmitted diseases.  Western Journal of Nursing Research, 23(3), 241-254.
• Champion, J.D., Piper, J., Shain, R., Perdue, S, (2001b) Minority women with STD: Sexual abuse and risk of PID.  Research in Nursing and Health, 24, 38-43.
• Champion JD, Piper J, Holden A, Korte J, Shain RN. Abused women and risk for pelvic inflammatory disease. West J Nurs Res. 2004;26:176-1791.
• Champion JD, Piper JM, Holden AE, et al. Relationship of abuse and pelvic inflammatory disease risk behaviour in minority adolescents. J Am Acad Nurse Pract. 2005;17:234-241.
  Jensen JR, Shain RN, Holden AE, et al. Concern about the effects of STDs on future fertility can be learned and is associated with lower risk-taking behaviours in an inner-city minority population. Note: As presented at ASRM 2006?
• Shain RN, et al. A randomized, controlled trial of a behavioural intervention to prevent sexually transmitted disease among minority women. N Engl J Med. 1999 Jan 14;340(2):93-100.
• Peterman TA. Does measured behaviour reflect STD risk? An analysis of data from a randomized controlled behavioural intervention study. Project RESPECT Study Group. Sex Transm Dis. 2000 Sep;27(8):446-451.
• Shain RN, et al. Behaviours changed by intervention are associated with reduced STF recurrence: the importance of context in measurement. Sex Transm Dis. 2002 Sep;29(9):520-9.