Crosby, Richard A. PhD*†; Liddon, Nicole PhD‡; Martich, Frederick A. BS‡; Brewer, Toye MD§
From the *Rollins School of Public Health, Department of Behavioral Sciences & Health Education, Atlanta, Georgia; †Emory Center for AIDS Research, Atlanta, Georgia; ‡Center for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of STD Prevention, Atlanta, Georgia; and §University of Miami, School of Medicine, Miami, Florida
Correspondence: Richard A. Crosby, PhD, College of Public Health, Department of Health Behavior, University of Kentucky, 121 Washington Ave., Room 111C, Lexington, KY 40506-0003. E-mail: email@example.com
Received for publication October 17, 2003, revised January 27, 2004, and accepted February 11, 2004.
In women, infection with Neisseria gonorrhoeae substantially contributes to the incidence of pelvic inflammatory disease and infertility.1–3 Clearly, one aspect of preventing the transmission of these infections to women (who are likely to be asymptomatic after infection) may be intervention with male index cases (who, conversely, are likely to experience prominent symptoms). One potentially important, but understudied, phenomenon in the male-to-female transmission of gonorrhea is whether men engage in unprotected sex after they experience symptoms.
Findings from previous studies suggest that men may delay seeking care after experiencing symptoms (e.g., discharge or dysuria) and they may engage in unprotected sex during this time.4–6 One study of men and women recruited from 10 STD clinics in 7 cities found that more than 80% of men experiencing symptoms reported they did not always use condoms during the symptomatic period.6 The study tested several demographic variables for their association with this risk behavior; however, behavioral variables were limited (e.g., days of symptom duration and self treatment were assessed). With the exception of one study,4 these investigations did not specifically investigate the STD most likely to produce dysuria and discharge: gonorrhea.
Accordingly, the purpose of this exploratory study was to identify the prevalence and behavioral correlates of engaging in unprotected sex while experiencing symptoms dysuria or discharge among a clinic-based sample of men with a laboratory confirmed diagnosis of gonorrhea.
From September 2001 through August 2002, men (18 years of age or older) attending an STD clinic in Miami, FL were recruited for participation in the study. Inclusion criteria included a presumptive diagnosis of gonorrhea or nongonococcal urethritis. This criterion allowed us to specifically sample men who were experiencing symptoms typical of gonococcal infection. Thus, symptomatic men were eligible for the study and asymptomatic men were not (given that the presumptive diagnosis required symptomatology and a confirmatory Gram stain). Furthermore, men were eligible if they indicated having sex with a female partner in the past 30 days. Of 348 eligible men, 273 volunteered to participate (yielding a response rate of 78%). For analyses, we included only men with a laboratory confirmed diagnosis of gonorrhea (with or without a concurrent diagnosis of chlamydia) by DNA amplification of urine (n = 244). We further restricted the analytic sample to men who experienced dysuria or discharge (n = 237).
Men provided informed consent. The Institutional Review Board at the Centers for Disease Control and Prevention, the State of Florida, and the University of Miami approved the study protocol before implementation.
During a clinician’s exam, men were checked for discharge and asked about recent discharge and dysuria. Following presumptive diagnosis, a trained Disease Intervention Specialist conducted a brief face-to-face interview in a private setting and asked questions about numbers of sex partners, frequency of sex, condom use (past 30 days), sex with a casual partner, history of treatment for gonorrhea or chlamydia, and whether they had ever been diagnosed with an STD.
Subsequently, men provided a first-voided urine specimen. Until July 2002, all urine specimens were tested for N gonorrhoeae and C trachomatis using ligase chain reaction (LCx; Abbott Laboratories, Chicago, IL) according to manufacturer’s instructions. In July and August of 2002, men were tested using the Aptima Combo 2 assay (Gen Probe, San Diego, CA). Men were compensated $10.00 for their participation in these procedures.
Because of non-normality, continuous variables were dichotomized by performing a median split. Strength of association between the assessed correlates and the outcome measure was assessed by the use of prevalence ratios, their 95% confidence intervals, and their respective P-values. Significance was defined by an alpha level of 0.05 or less.
Correlates achieving a screening level of bivariate significance (P≤ 0.10) were entered into logistic regression model using a forward stepwise method. The logistic regression model was used to calculate adjusted odds ratios (AOR), their 95% confidence intervals, and corresponding P-values of the correlates that remained significant.
Characteristics of the Sample
Average age was 28.1 years (standard deviation = 8.6). The majority (88.2%) were black; 10.5% were white with Hispanic ethnicity, and the remainder were non-white Hispanics. About 6 of every 10 men (59.9%) reported multiple sex partners and more than two-thirds (68.8%) reported having sex with a casual partner. Men reported having sex a mean of 8.2 times (standard deviation = 8.8) in the last 30 days. The majority (54.0%) reported a history of STD. Most (78.9%) tested positive for gonorrhea alone, with the remainder testing positive for both infections. About two-thirds (66.2%) reported having dysuria and discharge, 27.5% reported discharge only, and 6.6% reported dysuria only. Nearly 60% (58.2%) percent reported ever being treated for gonorrhea or chlamydia in the past. About one-fifth (21.1%) reported having unprotected sex while experiencing dysuria or discharge.
Table 1 displays the percent of men reporting unprotected sex while experiencing symptoms for each category (e.g., yes versus no) of the assessed correlates. For example, 29.4% of men reporting they had sex at least 5 times in the past 30 days engaged in unprotected sex while experiencing symptoms. Conversely, only 11.7 of those reporting sex 4 or fewer times engaged in unprotected sex while symptomatic. Table 1 also displays the corresponding prevalence ratios, their 95% confidence intervals, and respective P-values. As shown, 3 of the 8 correlates tested achieved significance and 2 additional correlates achieved a screening level of significance (i.e., P ≤ 0.10).
The multivariate model was significant (χ2 with 3 df = 24.18, P < 0.0001), and achieved satisfactory fit with the data (Goodness of Fit χ2 with 6 df = 0.54, P = 0.99). Age did not achieve significance (P = 0.07). Experiencing both discharge and dysuria did not achieve significance (P = 0.34). Men having sex 5 times or more in the past 30 days were about 3.5 times more likely to report having unprotected sex while experiencing symptoms (AOR = 3.53, 95% CI = 1.66–7.51, P = 0.001) compared to men having sex less frequently. Men who reported using condoms ≤50% of the times they had sex in the past 30 days were 2.7 times more likely to report having unprotected sex while symptomatic (AOR = 2.70, 95% CI = 1.29–5.65, P = 0.008). In addition, men reporting they had not had an STD in the past were about 2.7 times more likely to report the risk behavior (AOR = 2.68, 95% CI = 1.32–5.45, P = 0.006) compared to men reporting a previous infection.
In this study of symptomatic men, more than one-fifth reported having unprotected sex while experiencing dysuria, discharge, or both of these very salient problems. Given the markedly high infectivity rate of gonorrhea,1 the lack of condom use among infected men clearly poses a substantial risk of transmission to their female partners and thus represents an important challenge to control and prevention efforts. Therefore, findings from this exploratory study could be quite useful regarding subsequent research and program implementation designed to reduce the incidence of male-to-female transmission of gonorrhea.
The prevalence of the assessed risk behavior was markedly lower compared to a recent study that was not restricted to gonorrhea. In the multisite study reported by Irwin and colleagues more than 80% of the men reported having unprotected sex while experiencing symptoms of an STD.6 Our findings suggest that the rather salient symptoms associated with gonorrhea (i.e., dysuria and discharge) may prompt most, but not all, men to avoid unprotected sex after they experience one or both of these events. Thus, one important question becomes, who are the men that persist in having unprotected sex despite the experience of these prominent symptoms?
Findings from this exploratory study suggest that men who have sex on a relatively frequent basis and men who report using condoms infrequently may be those men who also persist to engage in unprotected sex after experiencing dysuria or discharge. Subsequent investigations should determine whether men who have an affinity for frequent unprotected sex are the same men who persist in this behavior even after onset of gonorrhea-associated symptoms. Indeed, from an epidemiologic perspective, these men may be an especially important group in the propagation of gonorrhea; therefore, intensified prevention efforts regarding their symptomatic sexual risk behavior may be warranted.
Of great interest, men who had never been diagnosed with an STD were especially likely to engage in unprotected sex after experiencing dysuria or discharge (independent of age). It is conceivable that men who have previously been diagnosed with an STD may have learned (either through counseling or the experience of diagnosis and treatment) to associate genital symptoms with STDs and to avoid unprotected sex after the onset of symptoms. Conversely, those who have never had an STD may initially be unaware of the significance of these symptoms. This observation suggests that clinic-based counseling may indeed be a critical aspect of the post-diagnostic process. Indeed, this counseling may be especially important for men with a proclivity for frequent unprotected sex.
The absence of significant associations between the outcome and several correlates is also particularly interesting. Contrary to expectations, the presence of both discharge and dysuria was not significantly associated with engaging in sex after symptom onset. Similarly, engagement in the risk behavior did not vary as a function of age, past treatment, having multiple sex partners (past 30 days), or reporting sex with a casual partner in the past 30 days. The latter 2 null findings suggest the possibility that men may be indiscriminately engaging in unprotected sex (after the onset of dysuria or discharge) with new partners, steady partners, and nonsteady partners.
Findings from this exploratory study can inform the design and nature of subsequent research. In particular, the question of why symptomatic men engage in unprotected sex while experiencing dysuria or discharge is clearly important. Several plausible hypotheses could be investigated. For example, men may not readily accept that dysuria or discharge is symptomatic of an STD and therefore they may engage in unprotected sex as frequently as they normally would without having these symptoms. However, given the rather poignant nature of these symptoms, other possibilities should also be investigated. Perhaps, for example, men engage in unprotected sex while symptomatic simply because they have not yet accessed treatment and cannot postpone the gratification derived from having unprotected sex. Qualitative research would certainly be an excellent strategy for revealing various reasons why men engage in this risk behavior and (perhaps knowingly) place their sex partners at-risk of gonococcal infection.
These findings are limited by the validity of the self-reported measures. In particular, we are concerned that (due to social desirability bias) men may have underreported the incidence of having sex while experiencing dysuria or discharge. Findings are also limited by the low statistical power afforded by the small sample size. For example, the effect size difference (about one-third) between men experiencing both discharge and dysuria compared to those experiencing only one symptom was substantial and may achieve significance (showing a protective effect) in the context of study with a larger sample. Findings are also limited by the use of a convenience sample thereby precluding generalization. In addition, it should be noted that the interview questions were not designed to distinguish between frequency of sex (and condom use) before the experience of dysuria or discharge as opposed to afterwards. Further research should make this distinction thereby enabling the study to determine if (for example) frequency of sex declined significantly after symptom onset. Further research is needed with diverse populations of men diagnosed with gonorrhea and chlamydia, particularly in private practices where many STDs are diagnosed.
Findings from this exploratory study suggest that men engaging in frequent sex, those using condoms infrequently, and those never having an STD may be especially likely to engage in unprotected sex after the onset of gonorrhea-associated dysuria or discharge. Thus, counseling protocols could potentially benefit these men by teaching them about the importance of abstaining from sex during times when they experience dysuria or discharge. Counseling designed to inform men how to better recognize symptoms and talking with them about the strong potential for gonorrhea to cause pelvic inflammatory disease in their female partners (along with an explanation of the sequelae caused by PID) could be a key aspect of this counseling.
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2. Bolan G, Ehrhardt AA, Wasserheit JN. Gender perspectives and STDs. In: Holmes KK, Sparling PF, Mardh P, et al. (Eds.) Sex Transm Dis New York, NY: McGraw Hill; 1999:117–128.
3. Centers for Disease Control, Prevention. Sexually transmitted diseases treatment guidelines, 2002. MMWR 2002; 51:1–78.
4. Upchurch DM, Brady WE, Reichart CA, Hook EW. Behavioral contribution to acquisition of gonorrhea in patients attending an inner city sexually transmitted diseases clinic. J Infect Dis 1990; 161:938–941.
5. Hook EW, Charity MR, Leone P, et al. Delayed presentation to clinics for sexually transmitted diseases by symptomatic patients. Sex Transm Dis 1997; 24:443–448.
6. Irwin DE, Thomas JC, Spitters CE, et al. Self-reported sexual activity and condom use among symptomatic clients attending STD clinics. Sex Transm Dis 1999; 26:286–290.