Download Counseling women about safe sex practices

Counseling women about
safe sex practices
By Laura S. Dalton, DO
Sexually transmitted diseases (STDs) do
not play fair––especially for women! To illustrate this point, I would like to share the
following facts:
䡲 Women have more risks for, and may
have fewer warning symptoms of, STDs
than men.1,2
䡲 Women are more likely to receive sexually transmitted infections from their male
partners than vice versa.1,2
䡲 Risky behaviors are the determinants of
a woman’s STD risk––not age, ethnicity, or
socioeconomic status.3
䡲 The STD risk status of a woman is
frequently out of her control, depending
on the sexual activities of her partner.
䡲 STD risk assessment may be difficult in
a busy primary care practice.
Safer sex means being smart and staying
healthy. The lowest-risk sexual behaviors are,
first, abstinence and, next, a long-term, mutually monogamous relationship. However,
because these behaviors will not be characteristic of many of our patients, we have
to abandon the “all or none” thinking
approach to patients’ sexual practices.
The spectrum of patients’ STD risk
ranges from very low (eg, having one sexual partner and using condoms 100% of
the time) to very high (eg, having frequent
unprotected sexual intercourse with multiple partners).
In the counseling of a sexually active female patient, the physician’s goal should be
to help the patient realistically view her
present level of risk and establish her comfort zone along the continuum of risk.
With this goal in mind, we can then assist
her with a patient-centered plan of care.
10
Safer sex is risk reduction—not elimination of risk. Dogmatic approaches, such
as “just say NO!” or “no sex until marriage,” may generate guilt, shame, and
hopelessness—especially in young patients.
As a result, these patients may not share
their symptoms or fears with their physicians, and we lose our opportunity to promote healthy behavioral changes.
Physicians are good at negotiating
healthy, incremental changes in patients
with obesity, diabetes mellitus, and cardiovascular disease. We can use these same
skills to help our patients reduce their morbidity and mortality from STDs.
Effective STD prevention counseling
for women incorporates the following elements:
䡲 Risk assessment and accurate evaluation
of present sexually transmitted infections.
䡲 Identifying barriers to STD risk
reduction.
䡲 Identifying misconceptions about, and
denial of, STD risk.
䡲 Encouraging skill-building strategies for
reducing STD risk.
䡲 Acknowledging STD risk-reduction
efforts.
䡲 Developing a patient-guided plan of
behavioral change.
䡲 Referring patients with comorbidities
to appropriate healthcare centers.
Risk assessment and evaluation
Project RESPECT was a large, multicenter,
randomized controlled trial illustrating the
effectiveness of STD prevention counseling in patients, especially those in high-risk
populations.4 According to the trial results,
short face-to-face counseling interventions
using personalized risk-reduction plans can
increase condom use and prevent new
STDs. The Project RESPECT researchers
found that this kind of effective counseling
doms and contraceptives; her use of spermicides with nonoxynol-9; and her history of abnormal Papanicolaou (Pap) smear
results or STDs. In addition, the patient
should be asked to describe her previous
treatments for STDs and her immunization history (including vaccinations for
human papillomavirus [HPV] and hepatitis B), as well as any signs or symptoms of
current STDs.5,6
The physician should help the patient
identify potential barriers to reducing her
4 million teenaged girls contract an STD,
every year.2 Sharing such statistics with
patients may help correct common misconceptions.
A number of other misconceptions can
lead to risky behaviors. In some cases, it may
be necessary for a physician to point out
that “serial monogamy” is not safe—unless
both partners are evaluated and treated
prior to their relationship and unless both
agree to openly discuss their risks with each
other. Teenagers often have one serious
sexual partner, but also one or more casual
sexual partners. They may incorrectly believe
that, although condom use makes sense with
STD risk, such as inconsistent use of condoms, lack of contraception, multiple sexual partners, lack of partner notification
about sexually transmitted infections, and
failure to treat or follow-up on previous infections. The physician should allow the
patient to suggest a solution for achieving
risk reduction, such as “I will buy the condoms” or “I will abstain from sexual intercourse until my partner and I are free from
infection.” The patient can best decide
which goals are most achievable.7
Various misconceptions that the patient
might have about STDs can increase her
risk. For example, many women believe
“pregnancy or STD won’t happen to me.”
Nevertheless, approximately 750,000
teenaged girls become pregnant, and some
their casual partners, it is not necessary with
their steady partner because of a perceived
lower risk.8
Hormonal methods of contraception
have given many women confidence in
avoiding unwanted pregnancies, but they
may wrongly infer that STD incidence is
also reduced with contraception. Thus, the
need for protection against STDs must be
reinforced by the physician at every contraceptive-related visit of the patient.
It is also beneficial for physicians to
point out to patients that oral sex is not risk
free. Studies have shown that chlamydia,
gonorrhea, and human immunodeficiency
virus (HIV) can all be spread with only
oral sexual contact.9
Although condoms would help reduce
Barriers to risk reduction and
misconceptions
[
In the interview or questionnaire,
the patient should be asked
to identify the behavior or
circumstance that places her
most at risk.
can even be conducted in busy public clinics. Reductions of new STDs among trial
participants were greatest for adolescents
and adults who had STDs diagnosed at enrollment.4
Anyone engaging in sexual activity—
whether oral, vaginal, or anal in nature—
is potentially at risk for STDs. Risk assessment of a patient can be accomplished with
several open-ended questions about that
patient’s sexual partners, condom and contraceptive use, previous STDs and current
concerns. A short interview with the patient, conducted in a nonjudgmental manner, or the use of a questionnaire with verbal follow-up are effective vehicles for
identifying STD risk.5
In the interview or questionnaire, the
patient should be asked to identify the behavior or circumstance that places her most
at risk. Other specific areas to cover with
the patient include the genders and numbers of her sexual partners; her use of con-
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STD risk during oral sex, they are rarely
used for this sexual activity.9 Many women
may gain a false sense of security by assuming that, if their partner has an STD, he
would use a condom to protect her during
oral sex. This assumption, unfortunately,
could prove dangerous.
help from
supportive parents––such
as talking
with
their
Skill-building strategies
Interventions consisting of building patient
skills for reducing their STD risks—such
as role playing, managing partner expectations, negotiating with partners, and using
condoms—have been shown to be superior to information-only counseling. Jemmott et al7 compared a 20-minute one-onone skill-building counseling session, a
200-minute group skill-building counseling session, and information-only counseling sessions for their effects in reducing
episodes of unprotected sexual intercourse
and newly acquired HIV/STDs in highrisk patients. At 12-month follow-up, patients in the one-on-one and group skill-
[
With patients involvement in
risk-reduction efforts, an effective
individualized plan of behavioral
change and risk management can
be developed.
building sessions reported less unprotected
intercourse and fewer positive results for
STDs than did patients in informationonly counseling.7
These types of skill-building counseling sessions may be out of the realm of
some practices, so the use of informative
video recordings and/or Internet
resources may be necessary. The United
States Department of Health and Human
Resources has online downloadable booklets available to help parents communicate with their teen and preteen
children (“Parents, Speak Up!”) and to
help children communicate to their parents (“Teen Chat”) about sexual behavior
and STDs.10 Such resources can help
young female patients develop personal
safety strategies before a compromising
situation develops. In addition, eliciting
12
children
about sex and
setting expectations
for their children—has
been shown to reduce risky sexual behaviors in adolescent populations.11
Risk-reduction efforts
Successfully reducing a patient’s STD risk
is often a complex process involving many
social and behavioral factors. For example,
the patient has to initiate contact with a
healthcare provider; acquire information
about her present condition and future
risks; consider her future sexual activity;
take a potentially embarrassing public action (ie, purchasing condoms); use the condoms and other contraceptives correctly;
communicate and negotiate with her partner; and arrange future STD evaluations
and treatments.
The patients with the least social support often have difficulty mastering this
complex process. Thus, help from a patient’s physician and the physician’s staff are
essential for reducing her risk. Healthcare
providers should acknowledge and support
even small improvements that women
make in their STD prevention.7
Patient-guided plan of change
With patient involvement in risk-reduction
efforts, an effective individualized plan of
behavioral change and risk management
can be developed. When appropriate, the
patient should be immunized against hepatitis B. The physician should encourage
HPV vaccination in girls and women aged
9 to 26 years, according to Food and Drug
Administration recommendations.12
The physician may also want to discuss
emergency contraception with the patient,
providing a prescription if needed. Antibi-
otic prophylaxis for STDs, immune globulin for hepatitis, and post-exposure HIV
prophylaxis may be recommended after unprotected sexual
intercourse or sexual assault.13 Patients should be
encouraged to have evaluations of vaginitis and
pelvic pain, which need to be
managed to minimize the long-term effects of any STD.
Any patient with a history of chlamydia
or gonorrhea should be warned of possible
ectopic pregnancy—so that perinatal care
can begin early and pregnancy location can
be verified by ultrasound examination.14
Early medical management of the ectopic
pregnancy may help the patient avoid the
need for a surgical procedure and prevent
extensive damage to the patient’s reproductive system.
The possibility of perinatal transmission
of infection will prompt many women to
seek screening and treatment for STDs.
Eliminating STDs during pregnancy also
reduces rates of preterm labor and premature rupture of membranes.14
Adding barrier methods to a patient’s
contraceptive plan can help reduce STD
risk. Insisting on the use of condoms worn
by either partner is wise, because condoms
provide increased protection from both
HIV and STDs.4,15
The use of valacyclovir hydrochloride to
treat patients for acute genital herpes and
to suppress herpes simplex virus (HSV) recurrences reduces viral shedding and decreases the risk of passing the infection to
discordant (ie, uninfected) partners.1 In
2007, Nagot and colleagues16 also showed
that HSV suppression reduces HIV shedding, which may, in turn, reduce HIV
transmission.
Referring patients with
comorbidities
Patients with comorbidities, such as depression, alcohol abuse, drug abuse, domestic
violence, or mental health problems, should
be referred to appropriate healthcare centers
for adequate treatment. Without treatment,
such patients may not have the coping
mechanisms necessary to keep themselves
safe from either pregnancy or STDs.
Physicians must remember that women
who are in violent relationships may not be
able to make their own healthcare and contraception decisions. Furthermore, these
women may not be aware of additional personal risks that they face as a result of their
partners’ unsafe sexual behaviors. Thus,
when physicians make referrals for women
in violent relationships, these factors must
be carefully considered.
February 7, 2008. Available at: http://www.uptodate.
11. Laino C. Kids’ safe sex: supportive mom is key.
com/patients/content/topic.do?print=true&topicKey=s
WebMD Health News [serial online]. August 16, 2006.
tds/7593&view=print. Accessed July 15, 2008.
Available at: http://www.webmd.com/parenting/
news/20060816/kids-safe-sex-supportive-mom-is-key.
3. Cohen DE, Mayer KH. Primary care issues for HIV-
Accessed June 27, 2008.
infected patients. Infect Dis Clin North Am.
2007;21;49-70, viii.
12. FDA licenses new vaccine for prevention of cervical cancer and other diseases in females caused by
4. Kamb ML, Fishbein M, Douglas JM Jr, Rhodes F,
human papillomavirus [press release]. Rockville, Md:
Rogers J, Bolan G, et al. Efficacy of risk-reduction
Food and Drug Administration; June 8, 2006. Available
counseling to prevent human immunodeficiency virus
at: http://www.fda.gov/bbs/topics/news/
and sexually transmitted diseases: a randomized con-
2006/new01385.html. Accessed July 15, 2008.
trolled trial. Project RESPECT Study Group. JAMA.
1998;280:1161-1167.
13. Bates CK. Evaluation and management of sexual
assault victims. UpToDate [serial online]; last updated
5. Patient-administered sexual history questionnaire,
June 11, 2008. Available at: http://www.uptodateonline.
California STD/HIV Prevention Training Center. STD
com/patients/content/topic.do?topicKey=~pw2pieU01
Checkup Web site. Available at:
KYg0rp. Accessed July 29, 2008.
http://www.stdcheckup.org/provider/media/patient_q
uestionnaire.pdf. Accessed June 27, 2008.
14. American Academy of Pediatrics, The American
6. Fleming DT, Wasserheit JN. From epidemiological
for Perinatal Care. 6th ed. Elk Grove Village, Ill: Ameri-
synergy to public health policy and practice: the contri-
can Academy of Pediatrics; 2007.
College of Obstetricians and Gynecologists. Guidelines
bution of other sexually transmitted diseases to sexual transmission of HIV infection [review]. Sex Transm
15. Varghese B, Maher JE, Peterman TA, Branson BM,
Infect. 1999;75:3-17. Available at: http://www.
Steketee RW. Reducing the risk of sexual HIV trans-
pubmedcentral.nih.gov/picrender.fcgi?artid=1758168&
mission: quantifying the per-act risk for HIV on the
blobtype=pdf. Accessed July 8, 2008.
basis of choice of partner, sex act, and condom use.
Sex Transm Dis. 2002;29:38-43.
7. Jemmott LS, Jemmott JB 3rd, O’Leary A. Effects on
Final notes
Any female patient who is sexually active—
including oral, vaginal, or anal sex—is at risk
for an STD. We need to help her accurately assess her risk and apply behavioral improvements where possible. A healthy sexual relationship is built on love, trust and
communication. Physicians need to appreciate the difficulties that many women have
in seeking help with STD risks and treatment, and we should acknowledge and support even small improvements that these
women make in STD prevention. ❙ ww
sexual behavior and STD rate of brief HIV/STD preven-
16. Nagot N, Ouedraogo A, Foulongne V, Konate I,
tion interventions for African American women in pri-
Weiss HA, Vergne L, et al; ANRS 1285 Study Group.
mary care settings. Am J Public Health. 2007;97:1034-
Reduction of HIV-1 RNA levels with therapy to
1040. Epub April 26, 2007.
suppress herpes simplex virus. N Eng J Med.
2007;356:790-799. Available at: http://content.nejm.org/
8. Centers for Disease Control and Prevention (CDC).
ing epidemic-United States, 2003. MMWR Morb Mor-
tal Wkly Rep. 2003;52:329-332.
9. Centers for Disease Control and Prevention (CDC).
Transmission of primary and secondary syphilis by oral
sex-Chicago, Illinois, 1998-2002. MMWR Morb Mortal
Wkly Rep. 2004;53:966-968. Available at: http://
www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.
References
htm. Accessed July 29, 2008.
1. Principles of risk reduction counseling. In: Klausner
JD, Hook EW III. Current Diagnosis & Treatment of
10. US Department of Health and Human Services.
Sexually Transmitted Diseases. New York City, NY:
Downloadable booklets and other information from
McGraw-Hill; 2007.
4Parents.gov program; last revised May 30, 2008.
Available at: http://www.4parents.gov/. Accessed
2. Gay CL, Cohen MS. Prevention of sexually transmit-
cgi/content/full/356/8/790. Accessed July 7, 2008.
Advancing HIV prevention: new strategies for a chang-
Laura S. Dalton, DO, FACOOG, is the medical
director of the Center for Women-Lumberton
in New Jersey. She is the immediate past president of the American College of Osteopathic
Obstetricians and Gynecologists, and she
serves on the American Osteopathic Association’s Conjoint Committee on Continuing Medical Education. Dr Dalton is also clinical assistant professor of obstetrics and gynecology at
the Philadelphia College of Osteopathic Medicine (PCOM) in Pa, and the University of Medicine and Dentistry of New Jersey-––School of
Osteopathic Medicine in Stratford. In addition,
Dr Dalton is a site coordinator for the PCOM
obstetrics/gynecology residency program. She
can be reached at [email protected].
June 27, 2008.
ted diseases. UpToDate [serial online]; last updated
13