Counseling women about safe sex practices - CECity

Counseling women aboutsafe sex practicesBy Laura S. Dalton, DOSexually transmitted diseases (STDs) donot play fair––especially for women! To illustratethis point, I would like to share thefollowing facts: Women have more risks for, and mayhave fewer warning symptoms of, STDsthan men. 1,2 Women are more likely to receive sexuallytransmitted infections from their malepartners than vice versa. 1,2 Risky behaviors are the determinants ofa woman’s STD risk––not age, ethnicity, orsocioeconomic status. 3 The STD risk status of a woman isfrequently out of her control, dependingon the sexual activities of her partner. STD risk assessment may be difficult ina busy primary care practice.Safer sex means being smart and stayinghealthy. The lowest-risk sexual behaviors are,first, abstinence and, next, a long-term, mutuallymonogamous relationship. However,because these behaviors will not be characteristicof many of our patients, we haveto abandon the “all or none” thinkingapproach to patients’ sexual practices.The spectrum of patients’ STD riskranges from very low (eg, having one sexualpartner and using condoms 100% ofthe time) to very high (eg, having frequentunprotected sexual intercourse with multiplepartners).In the counseling of a sexually active femalepatient, the physician’s goal should beto help the patient realistically view herpresent level of risk and establish her comfortzone along the continuum of risk.With this goal in mind, we can then assisther with a patient-centered plan of care.Safer sex is risk reduction—not eliminationof risk. Dogmatic approaches, suchas “just say NO!” or “no sex until marriage,”may generate guilt, shame, andhopelessness—especially in young patients.As a result, these patients may not sharetheir symptoms or fears with their physicians,and we lose our opportunity to promotehealthy behavioral changes.Physicians are good at negotiatinghealthy, incremental changes in patientswith obesity, diabetes mellitus, and cardiovasculardisease. We can use these sameskills to help our patients reduce their morbidityand mortality from STDs.Effective STD prevention counselingfor women incorporates the following elements: Risk assessment and accurate evaluationof present sexually transmitted infections. Identifying barriers to STD riskreduction. Identifying misconceptions about, anddenial of, STD risk. Encouraging skill-building strategies forreducing STD risk.10

Acknowledging STD risk-reductionefforts. Developing a patient-guided plan ofbehavioral change. Referring patients with comorbiditiesto appropriate healthcare centers.Risk assessment and evaluationProject RESPECT was a large, multicenter,randomized controlled trial illustrating theeffectiveness of STD prevention counselingin patients, especially those in high-riskpopulations. 4 According to the trial results,short face-to-face counseling interventionsusing personalized risk-reduction plans canincrease condom use and prevent newSTDs. The Project RESPECT researchersfound that this kind of effective counselingcan even be conducted in busy public clinics.Reductions of new STDs among trialparticipants were greatest for adolescentsand adults who had STDs diagnosed at enrollment.4Anyone engaging in sexual activity—whether oral, vaginal, or anal in nature—is potentially at risk for STDs. Risk assessmentof a patient can be accomplished withseveral open-ended questions about thatpatient’s sexual partners, condom and contraceptiveuse, previous STDs and currentconcerns. A short interview with the patient,conducted in a nonjudgmental manner,or the use of a questionnaire with verbalfollow-up are effective vehicles foridentifying STD risk. 5In the interview or questionnaire, thepatient should be asked to identify the behavioror circumstance that places her mostat risk. Other specific areas to cover withthe patient include the genders and numbersof her sexual partners; her use of condomsand contraceptives; her use of spermicideswith nonoxynol-9; and her historyof abnormal Papanicolaou (Pap) smearresults or STDs. In addition, the patientshould be asked to describe her previoustreatments for STDs and her immunizationhistory (including vaccinations forhuman papillomavirus [HPV] and hepatitisB), as well as any signs or symptoms ofcurrent STDs. 5,6Barriers to risk reduction andmisconceptionsThe physician should help the patientidentify potential barriers to reducing her4 million teenaged girls contract an STD,every year. 2 Sharing such statistics withpatients may help correct common misconceptions.A number of other misconceptions canlead to risky behaviors. In some cases, it maybe necessary for a physician to point outthat “serial monogamy” is not safe—unlessboth partners are evaluated and treatedprior to their relationship and unless bothagree to openly discuss their risks with eachother. Teenagers often have one serioussexual partner, but also one or more casualsexual partners. They may incorrectly believethat, although condom use makes sense withIn the interview or questionnaire,the patient should be askedto identify the behavior orcircumstance that places her[most at risk.STD risk, such as inconsistent use of condoms,lack of contraception, multiple sexualpartners, lack of partner notificationabout sexually transmitted infections, andfailure to treat or follow-up on previous infections.The physician should allow thepatient to suggest a solution for achievingrisk reduction, such as “I will buy the condoms”or “I will abstain from sexual intercourseuntil my partner and I are free frominfection.” The patient can best decidewhich goals are most achievable. 7Various misconceptions that the patientmight have about STDs can increase herrisk. For example, many women believe“pregnancy or STD won’t happen to me.”Nevertheless, approximately 750,000teenaged girls become pregnant, and sometheir casual partners, it is not necessary withtheir steady partner because of a perceivedlower risk. 8Hormonal methods of contraceptionhave given many women confidence inavoiding unwanted pregnancies, but theymay wrongly infer that STD incidence isalso reduced with contraception. Thus, theneed for protection against STDs must bereinforced by the physician at every contraceptive-relatedvisit of the patient.It is also beneficial for physicians topoint out to patients that oral sex is not riskfree. Studies have shown that chlamydia,gonorrhea, and human immunodeficiencyvirus (HIV) can all be spread with onlyoral sexual contact. 9Although condoms would help reduce11

STD risk during oral sex, they are rarelyused for this sexual activity. 9 Many womenmay gain a false sense of security by assumingthat, if their partner has an STD, hewould use a condom to protect her duringoral sex. This assumption, unfortunately,could prove dangerous.With patients involvement inrisk-reduction efforts, an effectiveindividualized plan of behavioralchange and risk management can[be developed.Skill-building strategiesInterventions consisting of building patientskills for reducing their STD risks—suchas role playing, managing partner expectations,negotiating with partners, and usingcondoms—have been shown to be superiorto information-only counseling. Jemmottet al 7 compared a 20-minute one-ononeskill-building counseling session, a200-minute group skill-building counselingsession, and information-only counselingsessions for their effects in reducingepisodes of unprotected sexual intercourseand newly acquired HIV/STDs in highriskpatients. At 12-month follow-up, patientsin the one-on-one and group skillbuildingsessions reported less unprotectedintercourse and fewer positive results forSTDs than did patients in informationonlycounseling. 7These types of skill-building counselingsessions may be out of the realm ofsome practices, so the use of informativevideo recordings and/or Internetresources may be necessary. The UnitedStates Department of Health and HumanResources has online downloadable bookletsavailable to help parents communicatewith their teen and preteenchildren (“Parents, Speak Up!”) and tohelp children communicate to their parents(“Teen Chat”) about sexual behaviorand STDs. 10 Such resources can helpyoung female patients develop personalsafety strategies before a compromisingsituation develops. In addition, elicitinghelp fromsupportive parents––suchas talkingwiththeirchildrenabout sex andsetting expectationsfor their children—hasbeen shown to reduce risky sexualbehaviors in adolescent populations. 11Risk-reduction effortsSuccessfully reducing a patient’s STD riskis often a complex process involving manysocial and behavioral factors. For example,the patient has to initiate contact with ahealthcare provider; acquire informationabout her present condition and futurerisks; consider her future sexual activity;take a potentially embarrassing public action(ie, purchasing condoms); use the condomsand other contraceptives correctly;communicate and negotiate with her partner;and arrange future STD evaluationsand treatments.The patients with the least social supportoften have difficulty mastering thiscomplex process. Thus, help from a patient’sphysician and the physician’s staff areessential for reducing her risk. Healthcareproviders should acknowledge and supporteven small improvements that womenmake in their STD prevention. 7Patient-guided plan of changeWith patient involvement in risk-reductionefforts, an effective individualized plan ofbehavioral change and risk managementcan be developed. When appropriate, thepatient should be immunized against hepatitisB. The physician should encourageHPV vaccination in girls and women aged9 to 26 years, according to Food and DrugAdministration recommendations. 12The physician may also want to discussemergency contraception with the patient,providing a prescription if needed. Antibioticprophylaxis for STDs, immune globulinfor hepatitis, and post-exposure HIVprophylaxis may be recommendedafter unprotected sexualintercourse or sexual assault.13 Patients should beencouraged to have evaluationsof vaginitis andpelvic pain, which need to bemanaged to minimize the long-term effectsof any STD.Any patient with a history of chlamydiaor gonorrhea should be warned of possibleectopic pregnancy—so that perinatal carecan begin early and pregnancy location canbe verified by ultrasound examination. 14Early medical management of the ectopicpregnancy may help the patient avoid theneed for a surgical procedure and preventextensive damage to the patient’s reproductivesystem.The possibility of perinatal transmissionof infection will prompt many women toseek screening and treatment for STDs.Eliminating STDs during pregnancy alsoreduces rates of preterm labor and prematurerupture of membranes. 14Adding barrier methods to a patient’scontraceptive plan can help reduce STDrisk. Insisting on the use of condoms wornby either partner is wise, because condomsprovide increased protection from bothHIV and STDs. 4,15The use of valacyclovir hydrochloride totreat patients for acute genital herpes andto suppress herpes simplex virus (HSV) recurrencesreduces viral shedding and decreasesthe risk of passing the infection todiscordant (ie, uninfected) partners. 1 In2007, Nagot and colleagues 16 also showedthat HSV suppression reduces HIV shedding,which may, in turn, reduce HIVtransmission.Referring patients withcomorbiditiesPatients with comorbidities, such as depression,alcohol abuse, drug abuse, domesticviolence, or mental health problems, shouldbe referred to appropriate healthcare centersfor adequate treatment. Without treatment,such patients may not have the copingmechanisms necessary to keep themselves12

safe from either pregnancy or STDs.Physicians must remember that womenwho are in violent relationships may not beable to make their own healthcare and contraceptiondecisions. Furthermore, thesewomen may not be aware of additional personalrisks that they face as a result of theirpartners’ unsafe sexual behaviors. Thus,when physicians make referrals for womenin violent relationships, these factors mustbe carefully considered.Final notesAny female patient who is sexually active—including oral, vaginal, or anal sex—is at riskfor an STD. We need to help her accuratelyassess her risk and apply behavioral improvementswhere possible. A healthy sexualrelationship is built on love, trust andcommunication. Physicians need to appreciatethe difficulties that many women havein seeking help with STD risks and treatment,and we should acknowledge and supporteven small improvements that thesewomen make in STD prevention. ❙ wwReferences1. Principles of risk reduction counseling. In: KlausnerJD, Hook EW III. Current Diagnosis & Treatment ofSexually Transmitted Diseases. New York City, NY:McGraw-Hill; 2007.2. Gay CL, Cohen MS. Prevention of sexually transmitteddiseases. UpToDate [serial online]; last updatedFebruary 7, 2008. Available at: http://www.uptodate.com/patients/content/topic.do?print=true&topicKey=stds/7593&view=print. Accessed July 15, 2008.3. Cohen DE, Mayer KH. Primary care issues for HIVinfectedpatients. Infect Dis Clin North Am.2007;21;49-70, viii.4. Kamb ML, Fishbein M, Douglas JM Jr, Rhodes F,Rogers J, Bolan G, et al. Efficacy of risk-reductioncounseling to prevent human immunodeficiency virusand sexually transmitted diseases: a randomized controlledtrial. Project RESPECT Study Group. JAMA.1998;280:1161-1167.5. Patient-administered sexual history questionnaire,California STD/HIV Prevention Training Center. STDCheckup Web site. Available at:http://www.stdcheckup.org/provider/media/patient_questionnaire.pdf. Accessed June 27, 2008.6. Fleming DT, Wasserheit JN. From epidemiologicalsynergy to public health policy and practice: the contributionof other sexually transmitted diseases to sexualtransmission of HIV infection [review]. Sex TransmInfect. 1999;75:3-17. Available at: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1758168&blobtype=pdf. Accessed July 8, 2008.7. Jemmott LS, Jemmott JB 3rd, O’Leary A. Effects onsexual behavior and STD rate of brief HIV/STD preventioninterventions for African American women in primarycare settings. Am J Public Health. 2007;97:1034-1040. Epub April 26, 2007.8. Centers for Disease Control and Prevention (CDC).Advancing HIV prevention: new strategies for a changingepidemic-United States, 2003. MMWR Morb MortalWkly Rep. 2003;52:329-332.9. Centers for Disease Control and Prevention (CDC).Transmission of primary and secondary syphilis by oralsex-Chicago, Illinois, 1998-2002. MMWR Morb MortalWkly Rep. 2004;53:966-968. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm. Accessed July 29, 2008.10. US Department of Health and Human Services.Downloadable booklets and other information from4Parents.gov program; last revised May 30, 2008.Available at: http://www.4parents.gov/. AccessedJune 27, 2008.11. Laino C. Kids’ safe sex: supportive mom is key.WebMD Health News [serial online]. August 16, 2006.Available at: http://www.webmd.com/parenting/news/20060816/kids-safe-sex-supportive-mom-is-key.Accessed June 27, 2008.12. FDA licenses new vaccine for prevention of cervicalcancer and other diseases in females caused byhuman papillomavirus [press release]. Rockville, Md:Food and Drug Administration; June 8, 2006. Availableat: http://www.fda.gov/bbs/topics/news/2006/new01385.html. Accessed July 15, 2008.13. Bates CK. Evaluation and management of sexualassault victims. UpToDate [serial online]; last updatedJune 11, 2008. Available at: http://www.uptodateonline.com/patients/content/topic.do?topicKey=~pw2pieU01KYg0rp. Accessed July 29, 2008.14. American Academy of Pediatrics, The AmericanCollege of Obstetricians and Gynecologists. Guidelinesfor Perinatal Care. 6th ed. Elk Grove Village, Ill: AmericanAcademy of Pediatrics; 2007.15. Varghese B, Maher JE, Peterman TA, Branson BM,Steketee RW. Reducing the risk of sexual HIV transmission:quantifying the per-act risk for HIV on thebasis of choice of partner, sex act, and condom use.Sex Transm Dis. 2002;29:38-43.16. Nagot N, Ouedraogo A, Foulongne V, Konate I,Weiss HA, Vergne L, et al; ANRS 1285 Study Group.Reduction of HIV-1 RNA levels with therapy tosuppress herpes simplex virus. N Eng J Med.2007;356:790-799. Available at: http://content.nejm.org/cgi/content/full/356/8/790. Accessed July 7, 2008.Laura S. Dalton, DO, FACOOG, is the medicaldirector of the Center for Women-Lumbertonin New Jersey. She is the immediate past presidentof the American College of OsteopathicObstetricians and Gynecologists, and sheserves on the American Osteopathic Association’sConjoint Committee on Continuing MedicalEducation. Dr Dalton is also clinical assistantprofessor of obstetrics and gynecology atthe Philadelphia College of Osteopathic Medicine(PCOM) in Pa, and the University of Medicineand Dentistry of New Jersey-––School ofOsteopathic Medicine in Stratford. In addition,Dr Dalton is a site coordinator for the PCOMobstetrics/gynecology residency program. Shecan be reached at dalton_300@msn.com.13