Characteristics of Study Participants
Of 4977 women presenting to the JCDH STD Clinic in 2007, 349 women (7.0%) reported ≥4 sex partners during the preceding 12 months. Two women were excluded from analysis because of incomplete data in the electronic medical record; 347 cases were analyzed in the final study. The median number of sex partners among cases during the preceding 12 months was 5 (range, 4–200). Women in the single partner control group were 91% black and 8% white and reflected the overall racial makeup of the clinic. Women reporting ≥4 sex partners in the preceding year were disproportionately white (33%) (P < 0.001). Women reporting ≥4 partners were also younger on average than women reporting a single recent partner (median age: 24 vs. 29 years of age, respectively; P < 0.001).
Women with ≥4 sex partners were more likely to report sex with both men and women (<0.0001) and to engage in nonvaginal (oral or rectal) sex (P < 0.0001). Although condom use was low in both groups, women with ≥4 sex partners were also more likely to report consistent condom use (P < 0.0001), but birth control, either reversible or nonreversible, was more prevalent among single partner women (P < 0.0001). Women with ≥4 sex partners in the preceding year were less likely to have received care previously in the JCDH STD Clinic (P < 0.0005) (Table 1).
Comparison of Reported Symptoms in Women With ≥4 Recent Sex Partners to Women Reporting a Single Recent Sex Partner
Approximately 70% of study participants were symptomatic at presentation. Self-reported rates of dysuria, genital itching, and vaginal bleeding were not significantly different between groups (data not shown). In contrast, women with ≥4 partners were more likely to report both dyspareunia (P = 0.02) and genital lesions (P = 0.02). They were also more likely to report extragenital symptoms, including skin rash (P = 0.0003) and lower abdominal pain (P = 0.001). Although the majority of women presenting to the STD clinic reported vaginal discharge, it was reported less often by women with multiple sex partners than those with a single sex partners (Table 2).
STI History and Diagnoses in Women With Multiple and Single Sex Partners
At each STD clinic visit, patients are asked whether they have a history of an STI, and when an STI history is reported to identify the STI. Review of this information revealed that a similar proportion of women from each group reported having ever had an STI (Table 3). However, women with ≥4 sex partners were more likely to report having had multiple STI's (P < 0.0001) than single partner controls. For specific STI's, women with ≥4 sex partners reported more gonorrhea (P = 0.04) and syphilis (P = 0.0007) (Table 3). There were no significant differences between groups with respect to a history of chlamydia, trichomoniasis, genital herpes, or genital warts (Table 3 and data not shown).
STI's were also diagnosed more frequently at the time of visit among women with ≥4 sex partners in the past year. At presentation for care, women with ≥4 sex partners in the preceding 12 months were significantly more likely to be diagnosed with chlamydia (P = 0.01) and/or gonorrhea (P = 0.02) by nucleic acid amplification tests and/or syphilis (P = 0.0006). There was no difference in trichomoniasis diagnoses between groups (Table 4).
Little is known about women attending STD clinics who report sex with multiple partners. In this article, we offer an initial effort to identify factors associated with this behavior, using a case–control study design to compare women who reported ≥4 recent sex partners to their single partner counterparts. Our results show that the population of women with ≥4 sex partners was different than the population of single partner controls. They were more racially diverse as a group with a higher prevalence of white women. They were also younger as a group. Women with ≥4 partners were more likely to acknowledge having nonvaginal sex or sex with same sex partners. They also were more likely to report a history of or have been diagnosed previously in the STD Clinic with (as captured in the electronic medical record) multiple STI's and specifically, a history of gonorrhea and syphilis. Women with ≥4 partners were diagnosed significantly more often with chlamydia, gonorrhea, or syphilis. Our data suggest that, even among women attending an STD clinic (a population with higher STI prevalence than the general population), there is a hierarchy of risk and sex partner number places a woman in a higher risk tier for acquiring STI's. Understanding the antecedents to having multiple sex partners is an important prelude to developing strategies to reduce partner number. Whereas our current, retrospectively collected data are insufficient to address the possibility, we hypothesize that the minority of women attending STD Clinics with the highest numbers of recent sex partners may themselves not be a homogenous group but may have different factors which contribute to their increased partner numbers. This hypothesis is deserving of further study as delineation of modifiable factors associated with increased numbers of recent sexual partners may help in refinement of STD control strategies for both this group of women and their sexual partners.
Of note, women reporting ≥4 sexual partners in the preceding year represent a special challenge because they were significantly less likely to have been previously seen at the STD clinic and, on presentation, were significantly more likely to present with more complex and potentially difficult to manage complaints such as abdominal pain, dyspareunia (suggesting pelvic inflammatory disease or its complications), or genital ulcer disease (suggesting syphilis or herpes). One way to interpret these findings is that women with multiple sex partners may be less likely to access care early in disease and may suffer more STI-related morbidity. Further research is needed to better understand how partner number is related to access to care and/or healthcare utilization.
Although the focus of this research was to characterize women with high-risk sexual behavior as determined by partner number, this study also serves to emphasize that risk factors, other than number of recent sex partners, influence STI acquisition in the majority of women attending our clinic. Observations from our experience as well as literature review demonstrate that most women seeking care in STD clinics have low numbers of recent sexual partners. In 2007, of approximately 5000 women seen at the JCHD STD Clinic, 89% reported ≤2 sex partners in the preceding year. Similarly, women treated in Baltimore STD Clinics reported a median of 2 sex partners in the preceding year with only 9.6% acknowledging >5 sex partners during the same period.13 Studies that define “recent” sexual partners as those occurring in the last 30 or 90 days, report similar findings.9,13 This observation may have important implications for management strategies offered to women attending public STD clinics. Despite low numbers of sexual partners in the majority of women, these women still have a high burden of STI's and risk reduction strategies are needed for this group. However, risk-reduction messages often focus on reducing partner number—an inappropriate message for most women. These data suggest that understanding the variables that influence each woman's risk for STI's are important to appropriately focus the risk reduction message.
For single partner women, it could be assumed that their regular male sex partner was the major contributor to their risk for STI acquisition by having concurrent sexual partners. Because this group of women has been treated for STI's in our STD clinic on multiple occasions a pattern of continued STI risk because of their steady male partner could be implied.16 It has been shown in persons with a steady sex partner that awareness of a partner's concurrency is often limited.16,17 Thus, to reduce risk of STI's among single partner women, concurrency needs to be delicately addressed providing women with strategies for self-protection. Equally important, attention must be turned toward the other half of the sexual dyad to reduce STI risk among the male counterpart.18,19
Of interest, the racial make-up of women who reported ≥4 recent sex partners did not reflect the racial make-up of the control group (or the clinic as a whole; data not shown). In fact, white women were disproportionately over-represented (33%). The reason for this is unclear; however, this finding will allow us to evaluate whether STI-related health disparities exist among women engaging in high risk sexual activity as determined by partner number. As demonstrated by Hallfors et al, young black adults with normative behaviors (i.e., low numbers of sex partners and low use of alcohol and drugs) have a higher prevalence of STI's than whites with the same behaviors.20 However, in the same study, black and white young adults with multiple partners did not have statistically significant differences in the prevalence of STI's, suggesting that having multiple sex partners may normalize risk of STI's between groups. In contrast, preliminary results from this study suggest that black women were more likely to report a history of STI's and they were more likely to be diagnosed with an STI at the time of presentation than white women with similar number of sex partners (data not shown) These findings suggest that disparities in STI's may also exist among women with relatively large numbers of sex partners attending our STD clinic (manuscript in preparation).
This study has several limitations. The data were collected from an electronic medical record and are limited to the variables available. No information regarding substance use, psychiatric history, or other demographic details were available. Thus, the electronic medical record does not allow for full exploration of the potential reasons why women have multiple sex partners including economic instability, intimate partner violence, or commercial sex work. A prospective analysis of women with multiple partners, evaluating their reasons for having multiple sex partners, is an important next step in this line of research. Much of the data were obtained by self–report and thus are inherently limited by recollection bias and/or potential falsification by the respondents. The current study was based on number of sex partners reported during a 12-month period. Therefore, we were unable to capture changes in partner number over time and how this influences STI prevalence. The case-control design assumes that controls are representative of all women attending the JCDH STD clinic. Differences between the control group and all women seen at the JCDH STD clinic reporting a single partner would lead to false associations and or missed associations. Although this is possible, comparison of the control group to the overall clinic population demonstrates that they are similar (data not shown). Finally, in this preliminary study, we looked at extremes in partner number. Data for women with 2 and 3 sexual partners were not included and for that reason, whether the differences found in these analyses represent a continuum of associations or not, are unknown.
In summary, this study demonstrates that women who report multiple recent sexual contacts remain at higher risk for STI's than single partner women presenting to our STD clinic. Further research is needed to define characteristics of and to understand the antecedents to high risk sexual behavior as defined by partner number. Additionally, this study highlights the diversity of women attending STD clinics and therefore a “one size fits all” approach to STI prevention is unlikely to be effective. Current STI prevention messages including promotion of condom use and partner reduction21–25 are vital but incomplete without an understanding of why women engage in high risk activity. Once this is understood, more effective and enduring interventions can be developed to reduce STI's.
1. Seth P, Wingood GM, Robinson LS, et al. Exposure to high-risk genital human papillomavirus and its association with risky sexual practices and laboratory-confirmed chlamydia among African-American women. Womens Health Issues 2009; 19:344–351.
2. DiClemente RJ, Crosby RA, Wingood GM, et al. Reducing risk exposures to zero and not having multiple partners: Findings that inform evidence-based practices designed to prevent STD acquisition. Int J STD AIDS 2005; 16:816–818.
3. Ghani AC, Swinton J, Garnett GP. The role of sexual partnership networks in the epidemiology of gonorrhea. Sex Transm Dis 1997; 24:45–56.
4. Koumans EH, Farley TA, Gibson JJ, et al. Characteristics of persons with syphilis in areas of persisting syphilis in the United States: Sustained transmission associated with concurrent partnerships. Sex Transm Dis 2001; 28:497–503.
5. Rosenberg MD, Gurvey JE, Adler N, et al. Concurrent sex partners and risk for sexually transmitted diseases among adolescents. Sex Transm Dis 1999; 26:208–212.
6. Senn TE, Carey MP, Vanable PA, et al. Sexual partner concurrency among STI clinic patients with a steady partner: Correlates and associations with condom use. Sex Transm Infect 2009; 85:343–347.
7. Thurman AR, Holden AE, Shain RN, et al. Preventing recurrent sexually transmitted diseases in minority adolescents: A randomized controlled trial. Obstet Gynecol 2008; 111:1417–1425.
8. Shain RN, Piper JM, Holden AE, 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.
9. Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new sexually transmitted infections in the year following a sexually transmitted infection: A case for rescreening. Ann Intern Med 2006; 145:564–572.
10. Helms DJ, Mosure DJ, Metcalf CA, et al. Risk factors for prevalent and incident Trichomonas vaginalis
among women attending three sexually transmitted disease clinics. Sex Transm Dis 2008; 35:484–488.
11. Satterwhite CL, Kamb ML, Metcalf C, et al. Changes in sexual behavior and STD prevalence among heterosexual STD clinic attendees: 1993–1995 versus 1999–2000. Sex Transm Dis 2007; 34:815–819.
12. Johnson HL, Erbelding EJ, Zenilman JM, et al. Sexually transmitted diseases and risk behaviors among pregnant women attending inner city public sexually transmitted diseases clinics in Baltimore, MD, 1996–2002. Sex Transm Dis 2007; 34:991–994.
13. Hook EW III, Reichart CA, Upchurch DM, et al. Comparative behavioral epidemiology of gonococcal and chlamydial infections among patients attending a Baltimore, Maryland, sexually transmitted disease clinic. Am J Epidemiol 1992; 136:662–672.
14. Santelli JS, Brener ND, Lowry R, et al. Multiple sexual partners among U.S. adolescents and young adults. Fam Plann Perspect 1998; 30:271–275.
15. Lauman EO, Gagnon J, Michael RT, et al. The Social Organization of Sexuality. Sexual Practices in the United Sates, 1st ed. Chicago, IL: The University of Chicago Press, 1994.
16. Drumright LN, Gorbach PM, Holmes KK. Do people really know their sex partners? Concurrency, knowledge of partner behavior, and sexually transmitted infections within partnerships. Sex Transm Dis 2004; 31:437–442.
17. Lenoir CD, Adler NE, Borzekowski DL, et al. What you don't know can hurt you: Perceptions of sex-partner concurrency and partner-reported behavior. J Adolesc Health 2006; 38:179–185.
18. Crosby R, DiClemente RJ, Charnigo R, et al. A brief, clinic-based, safer sex intervention for heterosexual African American men newly diagnosed with an STD: A randomized controlled trial. Am J Public Health 2009; 99(suppl 1):S96–S103.
19. Kamb ML, Fishbein M, Douglas JM Jr, et al; Project RESPECT Study Group. Efficacy of risk-reduction counseling to prevent human immunodeficiency virus and sexually transmitted diseases: A randomized controlled trial. JAMA 1998; 280:1161–1167.
20. Hallfors DD, Iritani BJ, Miller WC, et al. Sexual and drug behavior patterns and HIV and STD racial disparities: The need for new directions. Am J Public Health 2007; 97:125–132.
21. Jemmott LS, Jemmott JB III, O'Leary A. Effects on sexual risk behavior and STD rate of brief HIV/STD prevention interventions for African American women in primary care settings. Am J Public Health 2007; 97:1034–1040.
22. Lyles CM, Kay LS, Crepaz N, et al. Best-evidence interventions: Findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. Am J Public Health 2007; 97:133–143.
23. Warner L, Klausner JD, Rietmeijer CA, et al. Effect of a brief video intervention on incident infection among patients attending sexually transmitted disease clinics. PLoS Med 2008; 5:e135.
24. DiClemente RJ, Wingood GM, Harrington KF, et al. Efficacy of an HIV prevention intervention for African American adolescent girls: A randomized controlled trial. JAMA 2004; 292:171–179.
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25. DiClemente RJ, Salazar LF, Crosby RA. A review of STD/HIV preventive interventions for adolescents: Sustaining effects using an ecological approach. J Pediatr Psychol 2007; 32:888–906.