Sexually Transmitted Diseases:
Characteristics of Women Reporting Multiple Recent Sex Partners Presenting to a Sexually Transmitted Disease Clinic for Care
Van Wagoner, Nicholas J. MD, PHD*; Harbison, Hanne Sybil MSN, MSPH†; Drewry, Jonathan MPH, REHS*; Turnipseed, Elizabeth MD, MPH†; Hook, Edward W. III MD*†
From the *Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; and †Jefferson County Department of Health, Birmingham, AL.
Supported by the University of Alabama at Birmingham Infectious Diseases Training grant (T32–A152069–07) (to N.J.V.W.).
Correspondence: Nicholas J. Van Wagoner, MD, PhD, THT 229, 1530 3rd Avenue S., Birmingham, AL 35294. E-mail: firstname.lastname@example.org.
Received for publication February 22, 2010, and accepted August 8, 2010.
Background: Sexually transmitted disease (STD) clinic attendees are considered to be at higher risk of sexually transmitted infections (STIs) than the general population. However, little is known about STD clinic subpopulations and their unique risks for STI's. The goal of this project was to begin to characterize an important STD clinic subpopulation, the small proportion of women reporting a recent history of multiple sex partners.
Methods: Screening of electronic medical records from 2007 identified 347 (7%) women with ≥4 partners in the last 12 months. Records for women with ≥4 sex partners were matched with women reporting 1 sex partner in the last 12 months. Demographic, sexual history, STI history, and laboratory diagnosis(es) were extracted from the electronic medical record and compared using a case-control study design.
Results: Approximately 5000 women presented to our STD clinic in 2007; 7.0% reported ≥4 sex partners. Women with ≥4 sex partners were less often black and on average younger than women with single partners (Median age, 24 vs. 29). They reported more nonvaginal sex, more same-sex contacts, but more consistent condom use than women with single partners. Dyspareunia, genital lesions, abdominal pain, and skin findings were more commonly reported by women with ≥4 sex partners. Women with multiple partners were also more likely to report ever having had ≥3 STI's and were more likely to report a history of gonorrhea or syphilis. They were also more likely to be diagnosed at presentation with chlamydia, gonorrhea, or syphilis.
Conclusion: Women reporting multiple sex partners are an important minority among STD clinic attendees. Understanding the antecedents to high risk sexual behavior as determined by partner number is an important step in reducing STI's in this group.
Increased numbers of sex partners, sexual partner concurrency, and having a sex partner who has other partners are each associated with increased risk for sexually transmitted infection (STI) acquisition.1–6 Persons receiving care at public sexually transmitted disease (STD) clinics have a high prevalence of STI's and as such are often assumed to have a high prevalence of the characteristics mentioned above. Interventions to reduce risk for STI's provided in public STD clinics tend to target these characteristics, especially partner number.7,8 However, review of studies from STD clinics throughout the United States indicate that the majority of women receiving care in public STD clinics do not report large numbers of recent sexual partners. In fact, the median number of recent sex partners was one in these studies.9–13 This finding may have important implications for STI control. Thus, epidemiologic studies that describe sexual behaviors and STI-related risks for representative samples of women attending STD clinics may predominantly describe women with relatively small numbers of sexual partners, and characteristics of the minority of women attending STD clinics with relatively large numbers of sexual partners may be obscured by this majority. Because it is thought that individuals with multiple sex partners disproportionately contribute to community STI morbidity, there is a need to better characterize and understand this subpopulation of STD clinic attendees.
Consistent with data from other clinics9–13, in 2007, of 4977 women who presented for care to the Jefferson County Department of Health (JCDH) STD Clinic in Birmingham, AL, 2588 (54%) reported a single sex partner during the preceding 12 months whereas only 349 (7%) reported ≥4 sex partners in the preceding year. We hypothesize that women with multiple recent sexual partners also differ in other ways from the majority of women attending STD clinics and that understanding these differences may be important to community STI control as well as to proper counseling for individual patients. To begin to characterize this important subpopulation, we conducted a case–control study among women presenting to our STD clinic for care comparing women reporting ≥4 sex partners to a sample of women reporting a single sex partner during the previous year. Our intent was to understand how recent partner number influenced STI history, STI-related symptoms, and the likelihood of an STI diagnosis at presentation.
MATERIALS AND METHODS
A retrospective case–control study was performed to compare women with ≥4 sex partners (cases) in the preceding year to women reporting a single partner over the same period (controls) who attended the JCDH STD Clinic between January 1 and December 31, 2007. Records of patient visits to the JCDH STD Clinic have been recorded exclusively on an electronic medical record since August 1992. Using the clinic's electronic medical record, cases were comprised of the 349 women reporting ≥4 sex partners in the preceding 12 months and are compared to a sample of women reporting 1 sex partner during the same interval: each control was matched to a case patient on the basis of being seen for a new problem during the same week of presentation. For women presenting to the STD clinic more than once during the study period, cases and controls were defined by their first visit and only information up to and including this visit was analyzed. Data from all JCDH STD Clinic visits are recorded directly into the Clinic database using standardized, electronic history and physical examination forms. Demographic information, reason(s) for visit, symptoms, sexual history, STI history, and diagnosis(es) were extracted from the JCDH electronic medical record for each case and control using standardized data collection forms. History of previous visit was determined by review of the electronic medical record back to 1992. Any information that could potentially lead to the identification of study cases or controls was removed. Two cases were excluded because of incomplete data. A total of 347 cases were included in the final study with a matching number of controls. Before initiation of this study, it was approved by the JCDH and the University of Alabama institutional review board Committee.
Testing routinely performed for women attending the JCDH STD Clinic is performed at the Alabama Department of Public Health Laboratory and includes serological testing for syphilis and human immunodeficiency virus (consenting patients only), testing for Neisseria gonorrhoeae and Chlamydia trachomatis by nucleic acid amplification tests (Aptima-Combo 2, San Diego California) on endocervical swabs or urine specimens, and wet mount microscopy. Syphilis testing was performed using VDRL. Trichomoniasis was diagnosed by wet mount and direct visualization of Trichomonas vaginalis by light microscopy.
Data from the study data collection forms were scanned into an electronic database using Teleform software (Cardiff Software, Inc., San Marcos, CA). Data were first analyzed using descriptive and bivariate analyses. Independent variables previously shown to be associated with number of sex partners and also associated with high risk sexual behavior were assessed using Pearson χ2 (Tables 1–4).14,15 Logistic regression was performed to determine the association of having multiple sex partners with these independent variables (race, age, non-vaginal sex, condom use, birth control, and healthcare utilization). Odds ratios and 95% confidence intervals were calculated. A significance level of P < 0.05 was used as the cutoff for selecting associated independent variables. All data were analyzed using JMP™ (Version 8.0, SAS Inc., Cary, NC).
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.
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