Thurman, Andrea Ries MD; Holden, Alan E. C. PHD; Shain, Rochelle N. PHD; Perdue, Sondra T. DRPH
Young age is a well-known, independent risk factor for acquisition of sexually transmitted infections (STIs).1,2 In previous randomized controlled trials, we found that the Project Sexual Awareness For Everyone (SAFE) behavioral intervention significantly reduced the rate of recurrent Neiserria gonorrhea(GC) and or Chlamydia trachomatis (CT) among reproductive-age Mexican-American and black women.3,4 In addition, we determined that teen and adult women with STIs exhibited distinct high-risk behaviors which increased their risk of reinfection.5
Increasingly, public health policies have focused on wide-spread screening of men for CT and other strategies, such as expedited partner therapy, to break the cycle of heterosexual STI transmission and reinfection.6,7 By focusing on the high-risk sexual dyad, rather than the individual diagnosed with an STI, it is likely that a more comprehensive treatment and prevention effort will occur. In this study, we interviewed male partners of teen girls of age 15 to 19 years, infected with an STI versus men who are the sexual partners of adult women, age 20 years or older. We hypothesize that teen and adult women who acquire STIs are paired with men who have distinct risk factors, and identifying these male characteristics will help clinicians more effectively understand these high risk relationships, in order to assist the infected woman in partner notification, partner treatment and STI prevention.
Materials and Methods
Mexican-American and black women of age 15 to 45 years, diagnosed with a nonviral STI including GC, CT, syphilis, or Trichomonas vaginalis (TV) were referred to the Project SAFE research clinic. Most referrals were received from the San Antonio Metropolitan Health District clinics. Women were informed, before coming to our clinic, that in order to participate in the study, they had to invite their current male sexual partner (or a male with whom they have had sexual intercourse within the last 2 months) to the initial screening visit. Dyad enrollment occurred between September 1, 2005 and June 1, 2008.
After informed consent, all male and female participants were interviewed, examined, screened, and treated for STIs at intake and 6 and 12 months follow-up. Subject interviews were conducted separately and confidentially by trained research assistants, specific to the participant’s gender and ethnicity (for the female groups). Participants were encouraged to return to our clinic as needed for any symptoms of infection. At the intake and each follow-up visit, a physical examination was performed with collection of specimens for microbiologic testing, including GC, CT, syphilis, and TV. Thus, all men had STI testing at intake to confirm or exclude an STI. Men and women enrolled in Project SAFE were offered a test-of-cure after treatments and human immunodeficiency virus testing at each visit.
Dyads were randomized to 1 of 3 groups: (1) individual control counseling for both, (2) behavioral intervention for the female and control counseling for the male, or (3) behavioral intervention for both (separate male and female groups). The control counseling lasted approximately 15 minutes and was provided by nurse clinicians according to Centers for Disease Control guidelines.8 This control counseling focused on how STIs are acquired, compliance with treatment, symptoms, and possible sequelae of STIs, and prevention of STIs by condom use or avoidance of intercourse with infected partners. The Project SAFE behavioral intervention entailed 3, weekly, 3-hour, small-group, multicomponent behavioral cognitive interventions.3 We adapted the AIDS Risk Reduction Model to guide intervention development, supplemented with extensive ethnographic data to ensure suitability to our population. At intervention sessions, we used role-playing, interactive video, handouts, and group discussion to emphasize the preventive strategies of: abstinence, periodic abstinence, mutual monogamy, correct and consistent use of condoms, full compliance with treatment protocols, reduction in the number of partners, avoidance of sexual intercourse until the subjects completed treatment, taking time between partners to be selective, avoidance of douching and seeking medical care whenever a subject suspected infection. Overall goals were to have participants recognize their risk for contracting STIs, including human immunodeficiency virus, commit to behavior change, and acquire the necessary skills to effect change. The primary outcome of Project SAFE was subsequent reinfection with CT or GC. The data for this study were obtained from the intake male and female interviews. We enrolled 515 dyads, however, intake data from 1 dyad were missing, leaving 514 dyads for the analysis.
During the male intake interview, we asked participants to name all of their sexual partners within the last year. We recorded the approximate dates of first and last intercourse with each partner and defined a concurrent sexual relationship as having sex with 2 or more different partners during the same time period.
To estimate the number of acts of vaginal intercourse in the last 3 months, we asked men to estimate how many times per week they had vaginal intercourse with the index female. This number was multiplied by 12 to calculate a general estimate of number of vaginal sex acts in the last 3 months. If the dyad had been together for less than 3 months, total number of vaginal sex acts was calculated based on his estimates.
We assessed sensation seeking using a scale which has been previously validated in low income men and women9 by asking How strongly do you agree or disagree with these statements: (1) I like wild, free sex, or sex that “just happens” (2) “How it feels is the most important thing about sex” (3) “I enjoy the feeling of sex without a condom” (4) “When it comes to sex, people probably think I take risks” (5) “I am interested in trying out new kinds of sex” (6) “When it comes to sex, physical attraction is more important to me than how well I know the person” (7) “I enjoy the company of attractive people” (8) “I enjoy looking at sexy movies, magazines or pictures” (9) “I have said things that were not exactly true to get a person to have sex with me” (10) “Having sex with different people is an exciting idea” (11) “I like to have new and exciting kinds of sex.” Each question was scored 0 = “strongly agree,” 1 = “agree,” 2 = “disagree,” and 3 = “strongly disagree,” with an overall score of 0 to 33. Among men, a score of 13 or lower represented the 70th percentile or higher and was considered high sensation seeking.
At the female intake interview, 123 of 152 (80.9%) teen girls and 296 of 362 (81.8%) adult women reported that they had informed their male partner(s) about the STI diagnosis. Among these women, we asked “Did he agree that if you have an STI so does he, and that both of you need to get treated?” We categorized the following responses as the male agreeing that he was at risk of an STI exposure and needed to be tested and treated: “He agreed and got treated for the STI,” “He gave me a hard time but agreed and got treated,” and “He insisted that he didn’t have an STI, but he got treated.” We categorized the following responses as the male not agreeing that he might have been exposed or not agreeing to treatment: “He agreed, but I don’t know if he got treated,” “He agreed with me but never got treated,” and “He insisted he didn’t have an STI and did not get treated.” We asked both the man and woman to rate the level of closeness, commitment, and satisfaction they felt and that they perceived their partner felt with their relationship on a scale of 1 to 10, with 10 being the highest level of closeness, commitment, and satisfaction.
Bivariate relationships between categorical variables were first explored using Pearson χ square test and the Student t test was used for continuous variables. Variables which were statistically significant (P <0.05) in the bivariate analysis were further explored using multivariable forward stepwise logistic regression analysis, confirmed with a backward stepwise logistic regression analysis. SPSS (Chicago, IL) software was used for the analysis.
This study was approved by the Institutional Review Boards at the University of Texas Health Science Center at San Antonio and the San Antonio Metropolitan Health District.
There were 152 men partnered with teen girls of age 15 to 19 years and 362 men who were the sexual partners of adult women of age 20 years and older. Table 1 outlines the 2 male cohorts in terms of demographic, sexual, and behavioral risk factors. Many of the demographic differences in the male partners of teens versus adults are explained by the fact that the male partners of teens were significantly younger than the male partners of adults.
The male cohorts differed significantly in terms of several measures of sexual and behavioral risks including illicit drug use, having an STI at intake, shorter relationship length, shorter length of monogamy, and more sexual partners per year sexually active. However, other measures of sensation seeking were not significantly different between the male cohorts, including their mean sensation seeking scores and having an overall high composite sensation seeking score. When looking at the 11 individual measures of sensation seeking and sexual impulsivity, the mean score for each question was not significantly different between the men paired with teens versus the men paired with adults (data not shown).
Although the male cohorts were similar in their responses to what they received from the relationship with the index female, we used principal component analysis with varimax factor rotation and found that the 8 components of the relationship fell into 2 categories: practical (he receives housing, food, other financial help, and drugs and alcohol from the relationship) versus emotional factors (he receives emotional support, feelings of warmth and closeness, sense of family and belonging, and good sex from the relationship). When these factors were grouped, we found that the male cohorts were similar in what they received emotionally from the relationship (P = 0.84), but men paired with adult women were significantly more likely to report that they received practical/instrumental items from the relationship, as compared to male partners of teens (P = 0.04). There was an interaction between this finding and relationship length and marital status, as men paired with adult women were more likely to be married to her and had, on average, longer relationship length.
Teen girls enrolled in Project SAFE had an average of 2.34 ± 2.87 sexual partners per year sexually active, compared to adult women, who had a mean of 1.45 ± 1.51 sexual partners per year sexually active (P <0.001). Having concurrent sexual relationships in the last year was reported by 12.5% of teen girls and 11.9% of adult women (P = 0.84). The average age of the teen girls was 18.5 ± 1.3 years, while the adult women were on average 24.4 ± 3.8 years (P <0.001).
Table 2 examines risky sexual dyads, composed of a man and a woman who reported engaging in risky actions or behaviors that would limit communication and respect within the relationship. We included the variable of reporting that it was important to both him and her that she have his baby because pregnancy intentions are associated with condom use.10,11 Although all of the dyads were high risk, which was based on the fact that all women had an STI at intake, adult female dyads were more likely to be composed of a woman who used douches and a man who preferred that she use douches. The mean number of sexual partners per year sexually active for a teen girl and her male partner combined was significantly higher than for an adult woman and her male partner combined. Finally, teen girl dyads were more likely to be composed of a man and a girl who agreed that having a baby together was very important.
Table 3 contrasts the female’s perceptions of the man’s behavior, versus the actual behavior reported by the man. In all behaviors studied, the teen girls were not more naïve to their male partner’s behavior, as compared to the adult women. Because our study focused on risk factors for STI acquisition related to the male, we report on dyads where the male is participating in risky behavior, unbeknownst to the female.
Table 4 compares the level of closeness, commitment, and satisfaction that men and the women reported in their relationship. In addition, we contrast the female’s perception of her male partner’s report with his actual report. There was a trend that teen girls and their male partners reported similar levels of closeness, commitment, and satisfaction, and the teen girl correctly estimated her male partner’s report. In contrast, adult women reported significantly higher levels of closeness, commitment, and satisfaction than their male partners. In addition, adult women significantly overestimated the level of closeness and relationship satisfaction, reported by their male partners.
We performed a forward stepwise logistic regression analysis using the variables which were significant in the bivariate comparisons (P <0.05) to determine the essential risky features of men partnered with teens. Using the variables of his age, intake STI, drug use, number of sexual partners per year sexually active, and his desire to have a baby with the index female, we found that men partnered with teens were characterized by young age (P <0.001) (AOR: 0.73; 95% CI: 0.68, 0.79), current drug use (P = 0.01) (AOR: 1.81; 95% CI: 1.16, 2.81) and more sexual partners per year sexually active (P = 0.002) (AOR: 1.04; CI: 1.01, 1.06).
Finally, we performed logistic regression to describe what variables predicted STI infection in the male at intake. Using the variables of the index woman’s age, the man’s age, current drug use by the male, his and her number of sexual partners per year sexually active, and he believes it is really important for the index female to have his baby, we found that young age, measured as a continuous variable, was the factor that was independently predictive of the man having any STI at intake (P = 0.03) (AOR: 0.97; 95% CI: 0.94, 0.99).
We found that male partners of teen girls infected with an STI were more likely to be younger, have more sexual partners per year, sexually active, and were currently using any illegal drugs, as compared to the male partners of adult women infected with a nonviral STI. Like women, the variable which independently predicted infection in men was young age.1,2 Our data will assist clinicians in providing age-appropriate and partner-specific counseling to a teen girl or an adult woman diagnosed with an STI.
In an earlier analysis of teens with STIs, we found that 3 behaviors were highly associated with reinfection: rapid partner turnover (<3 months), unprotected sex with untreated partners, and nonmonogamy.5 In this analysis, we found that men partnered with teens, who are significantly younger, switch partners more rapidly as they begin having intercourse. As they encounter new sexual partners, their risk of infection is increased.2 We previously reported that teens who had unprotected sex with untreated partners were up to 10 times more likely to become reinfected with an STI.5 While this behavior was associated with reinfection in adults, the association was not as strong.5
Although all women entered our study with a laboratory-verified STI, only 257 of 514 (50%) of the men had an STI. It may be that the woman was infected by a man who was not invited to our study. However, all men enrolled in Project SAFE had risky sexual histories, reporting rates of concurrent sexual relationships in the past year that were more than double the rates reported in other national surveys.10,11 The male partners of teens were more likely to have an STI at intake. It is known that male-to-female transmission of STIs is generally more efficient than female-to-male transmission,2,12 although confounders such as anal intercourse, circumcision status, and comorbidities such as immune-suppression and STI coinfections must be considered.13 We initially hypothesized that the differences in male infection rates would be related to exposure frequency. However, the male cohorts reported similar frequencies of vaginal intercourse with the index female within the last 3 months. The mens’ cohorts were also not different in their low rates of consistent condom use. The higher incidence of STI infection among the men partnered with teens may be explained by the fact that these men had shorter periods of monogamy, and more sexual partners per year sexually active than men paired with adults. Thus, men matched with teens were more likely to be a “new partner,” which is a known risk for STI acquisition.2 Our data are consistent with previous work showing that young male age was an independent risk factor for infection with TV.14
Men partnered with teens were significantly more likely to report using any illegal drug once a month or more. Drug use among young men and women has been associated with STI acquisition, nonuse of condoms, and multiple sexual partners, likely due to complex interactions including risk disinhibition.15 Our data suggests that clinicians who diagnose teen girls with an STI should discuss the possible contributions of drug use and disinhibition on STI reinfection.
When comparing behavioral surrogates which we previously found to be associated with reinfection,5 we found that adult female dyads were more likely to be composed of a man who wanted his female partner to use douches and a woman who used douches. Douching has been associated with an increase in STI risk, but may be confounded by the fact that some women use douches in response to STI symptoms.16,17
Although our study highlights the risk characteristics of the men, we also found that teen dyads were characterized by specific risky behaviors. The mean combined number of sexual partners per year sexually active for the teen dyads was higher than for the adult dyads. Teen dyads were more likely to be composed of a male and female who thought it was very important to have children together. This may be because men paired with teens were younger, and had not yet fathered children. Although condom use has been shown to be low even among adolescents who want to avoid pregnancy, vigilance for consistent condom use is markedly decreased among teens who are ambivalent regarding future pregnancy, and those desiring pregnancy.18 Furthermore, a teen girl’s desire for pregnancy is highly influenced by her male partner’s wishes.19 Our data suggests that clinicians counseling teens on STI prevention may want to emphasize the implications of untreated STIs on fertility and pregnancy complications.
It has been shown that teen girls paired with older men are more likely to not use contraception, to desire pregnancy, drop out of school, use drugs, be diagnosed with an STI, and be involved in casual rather than committed relationships with multiple partners.20–27 Age difference is a surrogate for power differences and influence in the relationship, as age discordant couples have differences in maturity, sexual and life experiences, financial resources, education, and work attainment.27–29 We chose a 25% difference in age because this correlates with a 16-year-old girl partnered with a 20-year-old man, which meets 1 definition of statutory rape in Texas.30 Our data are in agreement with Kissinger et al, that although having an older male partner was a marker of various risks for teen girls, infection was most prevalent in young men and most adolescents are paired with young men.28
We found markers of influence by the male partners of teens, for example, they were more likely to be the father of the teen’s children and to report that it was very important for the teen to have his baby, which has been associated with sabotaging a teen girl’s request for condom use or contraception.31
Our data have several limitations. The cross sectional design of the study may not reflect ongoing behavior of the dyads, particularly dyads who received the Project SAFE behavioral intervention. The female had to invite a male sexual partner from within the past 2 months. It is not clear if the man who participated in the study was the man involved in the initial STI exposure. However, our method of our data collection, in which sexual dyads are interviewed separately by a gender matched individual, strengthens of our data. In addition, we have detailed, partner specific information on over 500 high risk sexual dyads, where at least 1 partner (the female) has a current, laboratory verified STI. The focus of this study was to provide data to help clinicians counsel women with STIs more effectively by describing their male partners and risky relationships. We certainly understand that women participate in risky behaviors, which increase the likelihood of recurrence in themselves or their partners.
In conclusion, a clinician who diagnoses an STI in a teen girl should know that her male partner is more likely to be young, infected with an STI, using illegal drugs, and have rapid partner turnover, as demonstrated by having more sexual partners per year sexually active. These men may exhibit influence over the teen by encouraging pregnancy or being the father of her children. These distinct characteristics are important triage questions to ask, when attempting to effectively counsel the teen on partner notification, partner treatment, and STI prevention practices.
1.Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2007. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services, 2008.
2.Centers for Disease Control and Prevention. 2006 sexually transmitted disease treatment guidelines. Morb Mortal Wkly Rep 2006:55.
3.Shain RN, Piper JM, Newton ER, et al. A randomized, controlled trial of a behavioral intervention to prevent sexually transmitted disease among minority women. N Engl J Med 1999; 340:93–100.
4.Shain RN, Piper JM, Holden AEC, et al. Prevention of gonorrhea and Chlamydia through behavioral intervention: Results of a two-year controlled randomized trial in minority women. Sex Transm Dis 2004; 31:401–408.
5.Thurman AR, Holden AEC, Shain RN, et al. Preventing recurrent sexually transmitted disease in minority adolescents: A randomized controlled trial. Obstet Gynecol 2008; 111:1417–1425.
6.Centers for Disease Control and Prevention. Male Chlamydia Screening Program, 2006. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services, 2007.
7.Centers for Disease Control and Prevention. Expedited Partner Therapy in the Management of Sexually Transmitted Diseases. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services, 2006.
8.Centers for Disease Control and Prevention. Trends in Reportable Sexually Transmitted Disease in the United States, 2005: National Data on Chlamydia, Gonorrhea, and Syphilis. Atlanta, GA: Centers for Disease Control and Prevention, 2006.
9.Kalichman SC, Rompa D. Sexual sensation seeking and sexual compulsivity scales: Reliability, validity and predicting HIV risk behavior. J Pers Assess 1995; 65:586–601.
10.Adimora AA, Schoenbach VJ, Doherty IA. Concurrent sexual partnerships among men in the United States. Am J Public Health 2007; 97:2230–2237.
11.Kirby D. Effective approaches to reducing adolescent unprotected sex, pregnancy, and childbearing. J Sex Res 2002; 39:51–57.
12.Nicolosi A, Leite MLC, Musicco M, et al. The efficiency of male-to-female and female-to-male sexual transmission of the Human Immunodeficiency Virus: A study of 730 stable couples. Epidemiology 1994; 5:570–575.
13.Powers KA, Poole C, Pettifor AE, et al. Rethinking the heterosexual infectivity of HIV-1: A systematic review and meta-analysis. Lancet Infect Dis 2008; 8:553–563.
14.Sena AC, Miller WC, Hobbs MM, et al. Trichomonas vaginalis infection in male sexual partners: Implications for diagnosis, treatment and prevention. Clin Infect Dis 2007; 44:13–22.
15.Parkes A, Wight D, Henderson M, et al. Explaining associations between adolescent substance use and condom use. J Adolesc Health 2007; 40:180.e1–e18.
16.Brotman RM, Ghanem KG, Klebanoff MA, et al. The effect of vaginal douching cessation on bacterial vaginosis: A pilot study. Am J Obstet Gynecol 2008; 198:628.e1–e7.
17.Tsai CS, Sheperd BE, Vermund SH. Does douching increase risk for sexually transmitted infections? A prospective study in high-risk adolescents. Am J Obstet Gynecol 2009; 200:38.e1–e8.
18.Bartz D, Shew M, Ofner S, et al. Pregnancy intentions and contraceptive behaviors among adolescent women: A coital event level analysis. J Adolesc Health 2007; 41:271–276.
19.Cowley C, Farley T. Adolescent girls’ attitudes toward pregnancy: The importance of asking what the boyfriend wants. J Fam Pract 2001; 50:603–607.
20.DiClemente RJ, Wingood GM, Crosby RA, et al. Sexual risk behaviors associated with having older sex partners: A study of black adolescent females. Sex Transm Dis 2002; 29:20–24.
21.Miller KS, Clark LF, Moore JS. Sexual initiation with older male partners and subsequent HIV risk behavior among female adolescents. Fam Plann Perspect 1997; 29:212–214.
22.DiClemente RJ, Wingood GM, Crosby R, et al. Parental monitoring: Association with adolescents’ risk behaviors. Pediatrics 2001; 107:1363–1368.
23.Darroch JE, Landry DJ, Oslak S. Age differences between sexual partners in the United States. Fam Plann Perspect 1999; 31:160–167.
24.Manning WD, Longmore MA, Giordano PC. The relationship context of contraceptive use at first intercourse. Fam Plann Perspect 2000; 32:104–110.
25.Rickert VI, Wiemann CM, Berenson AB. Health risk behaviors among pregnant adolescents with older partners. Arch Pediatr Adolesc Med 1997; 151:276–280.
26.Begley E, Crosby RA, DiClemente RJ, et al. Older partners and STD prevalence among pregnant African American teens. Sex Transm Dis 2003; 30:211–213.
27.Johnston-Briggs BD, Liu J, Carter-Pokras O, et al. Effect of partner relationship on motivation to use condoms among adolescent mothers. J Nat Med Assoc 2008; 100:929–935.
28.Kissinger P, Clayton JL, O’Brien ME, et al. Older partners not associated with recurrence among female teenagers infected with Chlamydia trachomatis. Sex Transm Dis 2002; 29:144–149.
29.Agurcia CA, Rickert VI, Berenson AB, et al. The behavioral risks and life circumstances of adolescent mothers involved with older adult partners. Arch Pediatr Adolesc Med 2001; 155:822–830.
30.Texas Penal Code Section 22.011.
31.Miller E, Decker MR, Reed E, et al. Male partner pregnancy-promoting behaviors and adolescent partner violence: Findings from a qualitative study with adolescent females. Ambul Pediatr 2007; 7:360–366.