Unfulfilled postpartum sterilization requests.

OBJECTIVE: To determine individual and delivery characteristics of women least likely to obtain a requested postpartum tubal ligation (PPTL) and, secondarily, to compare the postpartum contraceptive choices of women with an unfulfilled sterilization request to women not requesting a PPTL. STUDY DESIGN: Record review ofwomen delivering a liveborn singleton between December 2007 and May 2008 at the University of Texas San Antonio. Primary outcomes were risk factors for not receiving a requested PPTL. Secondary outcome was to compare the postpartum contraceptive choices of women not receiving a PPTL to controls, women not requesting a PPTL. RESULTS: During the observation period, 429 of 1,460 women requested a PPTL; 296 (69%) received the procedure, and 133 (31%) did not. The majority of patients (332/429, 77.4%) were Hispanic. Pretest power analysis concluded that 107 women were required in each group. Cesarean delivery was associated with the highest likelihood of receiving a PPTL. Women receiving a PPTL were more likely (p < or = 0.05) to be a documented U.S. resident, married, of lower parity, have private or any medical insurance and to have received any prenatal care. Postpartum contraception among women with unfulfilled sterilization requests was similar to that among controls. CONCLUSION: Although financial and policy barriers exist, the majority of patients requesting a PPTL received the procedure.

The male sexual partners of adult versus teen women with sexually transmitted infections.

OBJECTIVES: We compared the male sexual partners of teen girls of age 15 to 19 years, currently infected with a sexually transmitted infection (STI) versus the male partners of adult women of age 20 to 41 years, with an STI to determine risk factors in these high-risk sexual dyads related to the male partner. STUDY DESIGN: Interview of 514 men who were partnered with 152 teen girls and 362 adult women, enrolled in Project Sexual Awareness for Everyone, a randomized controlled trial of behavioral intervention to reduce recurrent STIs. RESULTS: Compared to the male partners of adult women, male partners of teen girls were significantly more likely (P < 0.05) to be infected with any STI at intake. Men partnered with teens were younger and had significantly more sexual partners per year sexually active, shorter relationship length, and shorter length of monogamy with the index girls. They were more likely to report that it was "really important" for the teen to have their baby (P = 0.04) and were slightly more likely to be the father of her children (P = 0.17). Young age independently predicted STI infection in men. CONCLUSIONS: Although all women had an STI at intake, important differences were noted among the male partners of teens versus adults. Clinicians with similar populations may use this data to understand the characteristics of male partners of teens with STIs, in order to more effectively counsel adult and teen women on partner notification, treatment and STI prevention.

Effect of acculturation on the acceptability of potential microbicides and sexual risk-taking.

BACKGROUND: The objective was to determine the acceptability and use patterns of potential microbicides among African American (AA), acculturated Hispanic (AH), and less acculturated Hispanic (LAH) women. We measured baseline sexual risk-taking and the likelihood of behavioral change, given effective microbicides. METHODS: Interview of 506 Mexican-American and AA women, all of whom have a sexually transmitted infection enrolled in Project Sexual Awareness for Everyone. RESULTS: The 3 groups reported similarly high acceptance of potential microbicides (76%-83% P = 0.24). LAHs were most likely to report they would use microbicides covertly (P = 0.03). Given the possibility of effective microbicides, AHs were consistently more likely to report risk disinhibition. AHs, as compared to LAHs and AAs, respectively, were most likely to report that they would not use condoms, (53% vs. 33% vs. 30% P <0.001), would have a 1-night stand (18% vs. 8% vs. 6% P = 0.02), or would have sex with humans before they got to know them (18% vs. 8% vs. 6% P = 0.01). AHs were also most likely to say they would or probably would change from baseline safe sexual practices to unsafe sexual behaviors if potential microbicides were available. Age was controlled for in the analysis as AHs were younger than AAs and LAHs. CONCLUSIONS: Future microbicides were acceptable among this at risk cohort. Acculturation was a predictor of risk disinhibition and should be considered when tailoring sexually transmitted infection prevention messages, given the advent of effective microbicides.

The influence of depression on sexual risk reduction and STD infection in a controlled, randomized intervention trial.

BACKGROUND: A randomized controlled trial of SAFE, a cognitive/behavioral intervention, revealed that it significantly reduces reinfection and behavioral risks among participants compared with controls. However, studies suggest that depression may moderate intervention efficacy among affected persons because of impaired information processing, failure to recognize risk, or inability to change behavior. GOAL: We evaluated SAFE efficacy among depressed and nondepressed Mexican- and African American women after comparing initial risk factors by depression status. We further explored intervention effects in moderately and severely depressed women. STUDY DESIGN: We stratified 477 participants (249 intervention, 228 controls) according to their depression status at baseline determined by CES-D scores. Using chi and multivariate logistic regression, we evaluated differences in reinfection and behavioral risk at 6-month, 12-month, and 1-year cumulative follow-ups between groups within baseline depression strata. RESULTS: : At baseline, 74.4% of women were depressed and had significantly greater levels of behavioral risks than nondepressed women. At follow-up intervals, behavioral risks and reinfection rates were lower among intervention women compared with controls regardless of depression status. For example, at 1-year follow-up reinfection rates were 15.2% in nondepressed intervention women versus 21.4% in nondepressed controls (AOR = 0.6), and 18.6% in depressed intervention women versus 27.3% in depressed controls (AOR = 0.6). Moreover, reinfection was consistently lower among moderately and severely depressed intervention women than controls (moderately depressed: 19.3% vs. 27.2%, AOR = 0.6; severely depressed: 17.9% vs. 27.5%, AOR = 0.6). CONCLUSIONS: Despite significantly greater behavioral risk among depressed women at baseline, SAFE was equally successful in reducing reinfection and high-risk behavior among depressed and nondepressed participants.

Preventing recurrent sexually transmitted diseases in minority adolescents: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of a randomized controlled trial of the Sexual Awareness For Everyone (SAFE) behavioral intervention on teenagers (aged 14 to 18 years) compared with adult rates of reinfection with Neiserria gonorrhea or Chlamydia trachomatis cervicitis, and to identify behaviors associated with recurrent infection. METHODS: Mexican-American and African-American females with a nonviral sexually transmitted disease (STD) were enrolled in SAFE or assigned to the control group. All participants were interviewed and examined at baseline, 6, and 12 months. The primary outcome variable was reinfection with N. gonorrhea or C. trachomatis. Secondary outcomes were changes in risky sexual behavior. RESULTS: Teens randomized to participation in SAFE had a statistically lower incidence of recurrent N. gonorrhea and C. trachomatis at 0 to 6 months (52%, P=.04) and cumulatively (39%, P=.04) compared with teens in the control group. Cumulatively, teens as a group had higher rates of reinfection (33.1%) than adults (14.4%) (P<.001). Adolescent reinfection was explained by unprotected sex with untreated partners (adjusted odds ratio [OR] 5.58), nonmonogamy (adjusted OR 5.14), and rapid partner turnover (adjusted OR 2.02). In adults, reinfection was predicted by unprotected sex with untreated partners (adjusted OR 4.90), unsafe sex (adjusted OR 2.18), rapid partner turnover (adjusted OR 3.13), and douching after sex (adjusted OR 2.14). CONCLUSION: Sexual Awareness for Everyone significantly reduced recurrent STDs in teenagers. Adults and teens randomized to the SAFE intervention had significant decreases in high-risk sexual behaviors as compared with those in the control group. Although not specifically designed for teens, the SAFE intervention worked very well in this high-risk population. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov, ClinicalTrials.gov, HSC2004415H. LEVEL OF EVIDENCE: I.

Partner notification of sexually transmitted infections: a large cohort of Mexican American and African American women.

OBJECTIVES: To determine factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among low-income Mexican American and African American women and their male sexual partners. GOAL: To identify women most likely to notify their partners about an STI exposure. STUDY DESIGN: Cross-sectional analysis of 775 women with a nonviral STI. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. A comprehensive intake interview was used to obtain sociodemographic, psychosocial, communication, and relationship information for the patients and each male sexual partner. Chi square analysis and multivariate logistic regression analysis were used to determine factors independently associated with PN. RESULTS: The 775 women identified 1122 male sexual partners. Of women with 1, 2, and 3 or more partners, 87.9%, 41.4%, and 25.0% reported PN for all partners respectively. Logistic regression demonstrated that 5 variables independently predicted PN: a "steady" relationship (OR: 5.25; CI: 2.82-4.91), 1 partner (OR: 2.10; CI: 1.71-2.56), recent intercourse (OR: 1.37; CI: 1.21-1.54), anticipated ongoing sexual activity (OR: 1.48; CI: 1.04-2.10), and/or desire for pregnancy with that partner (OR: 1.68; CI: 1.10-2.58). Patient and partner sociodemographic variables were not significantly associated with PN. Responses to specific relationship and communication variables, although significant, did not remain independent in the final logistic regression model. CONCLUSION: Among low-income Mexican American and African American women, the perception that a relationship with individual partner(s) was committed was predictive of PN.

Behavioural interventions and abuse: secondary analysis of reinfection in minority women.

Sexually transmitted infection (STI), including AIDS disproportionately affects minority women with a history of physical or sexual abuse. The objective of this study was to evaluate the efficacy of gender- and culture-specific behavioural interventions and interactive STI counselling for high-risk minority women with a history of physical or sexual abuse over two years. African- and Mexican-American women with a non-viral STI were enrolled in a randomized trial. Follow-up screens and interviews occurred at six months and one and two years. The primary outcome was subsequent infection with chlamydia and/or gonorrhoea. Secondary analysis of primary outcomes was made by self-reported physical or sexual abuse. Logistic regression was utilized on an intention-to-treat basis. Baseline data from 853 women were included; the retention rate was 91%. Infection rates were higher in abused women in Year 1 (29% vs. 23.8%, P=0.12), Year 2 (23.4% vs.17.6%, P=0.03) and cumulatively (43.8% vs. 33.0%, P=0.003). Unadjusted association between abuse and reinfection was stronger for adolescents (<19 years) than adults in Year 1 (42.7% vs. 30.8%, P=0.03), Year 2 (32.7% vs. 22.0%, P=0.03) and cumulatively (59.4% vs. 43.3%, P=0.004). Corresponding rates for adults were Year 1 (17.8% vs. 17.0%, P=0.84), Year 2 (17.4% vs. 12.7%, P=0.23) and cumulatively (30.7% vs. 22.3%, P=0.08). Reinfection rates were further stratified by adolescence and substance use. Abused adolescents had consistently higher reinfection than non-abused adolescents and abused adults. In conclusion, risk-reduction interventions decreased infective episodes with chlamydia and/or gonorrhoea in the two-year study period for non-abused women. Abused women, particularly adolescents and substance users, had increased episodes in these study periods.

Cervicitis and genitourinary symptoms in women culture positive for Mycoplasma genitalium.

PROBLEM: Mycoplasma genitalium has been associated with male urethritis. We sought to relate M. genitalium to genitourinary signs and symptoms in women. METHOD OF STUDY: We compared 26 culture-positive women (group 1), 257 additional polymerase chain reaction-positive women (group 2), and 107 negative control women. We used logistic regression to evaluate signs and symptoms, controlling for co-infections, pregnancy, age, and intervention group assignment. RESULTS: Comparing group 1 with controls, we found significantly elevated odds ratios (ORs) for intermediate vaginal discharge (OR = 5.4; 95% confidence interval 1.01, 29.2) and action in response to discharge [3.9 (1.1, 13.5)]. Non-significant increases were observed for pathologic vaginal discharge [3.8 (0.78, 18.2)], pathologic dyspareunia [1.5 (0.25, 9.0)], vaginal odor [2.1 (0.75, 5.7)], and cervical mucopus [4.1 (0.74, 22.4)]. Group 2 results were similar, but showed no increase in cervical mucopus relative to controls. CONCLUSION: Infection with M. genitalium in women is independently related to increased genitourinary symptomatology.

Relationship of abuse and pelvic inflammatory disease risk behavior in minority adolescents.

PURPOSE: Little is known about the relationship between minority adolescent's experiences of sexual or physical abuse and the pathology of gynecological symptoms that might have an impact on the diagnosis of sexually transmitted disease (STD) or risk for pelvic inflammatory disease (PID). The objective of this study was to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID among Mexican American and African American adolescent women with a current STD. METHODS: Mexican American and African American adolescent women (n = 373) with an STD underwent a targeted physical exam and questioning regarding sexual or physical abuse, current genitourinary symptomatology, and risk behaviors known to be associated with PID to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms that impact diagnoses of STD and risk for PID. RESULTS: Bivariate comparisons found that abused adolescents (n = 232) reported more behaviors associated with increased risk for PID, including earlier coitus, more sex partners, higher STD recurrence, and delayed health-seeking behavior. Multivariate comparisons found that abused adolescents were more likely to report pathologic genitourinary symptomatology than those who were not abused. Clinicians reported more abnormal physical exams but did not make any more presumptive diagnoses of PID for abused than nonabused adolescents. CONCLUSIONS: Delayed treatment for PID dramatically worsens future fertility and chronic pelvic pain. These findings demonstrate that abused adolescent women are at high risk for PID. Because of its considerable impact on risk for PID, an assessment for abuse is essential in clinical management of adolescent women with STD and diagnosis of PID.

Development of composite symptom variables for quantitative analysis of genitourinary symptomatology in women.

Gonorrhoea and chlamydia infections in women are often regarded as asymptomatic. Syndromic management of sexually transmitted disease (STDs), however, is partially based on vaginal symptoms. We sought to better identify STD-associated symptoms in women by development of composite genitourinary symptom constructs. Standard symptoms were stratified, based on their descriptors (amount, frequency, severity, etc.), into pathological (likely to be STD-associated) and intermediate (unlikely to be STD-related). Simple symptoms and composite symptom constructs were significantly more common in women with STD infections (chlamydia, gonorrhoea and/or trichomonas) than those without infection (six months later). Logistic regression confirmed the association of each pathological symptom construct individually with gonorrhoea, chlamydia and trichomonas. Composite symptom constructs improve the specificity for detecting STD infections in women.

Rural Mexican-American adolescent sexual risk behavior.

CONTEXT: There is a need for community-based, culturally sensitive, cognitive-behavioral interventions to reduce sexual risk behavior among minority adolescents. Studies of adolescent risk and protective behaviors have focused on identifying modifiable psychosocial variables that predict differential outcomes for subsequent intervention efforts. Research has been scarce in studies of rural minority adolescent women. PURPOSE: To examine the protective and risk behaviors of these rural Mexican-American adolescent women and their relationship to physical or sexual abuse. METHODS: Mexican-American adolescent women aged 14-19 years were recruited through a rural health clinic and administered a self-report assessment for protective and risk behavior and sexual, physical, and psychological abuse. FINDINGS: Rural minority adolescent women endured high levels of psychological distress and many risk behaviors yet experienced few protective behaviors. Barriers to health care included access and confidentiality. Physically or sexually abused adolescents endured relatively greater risk and fewer protective behaviors than nonabused. CONCLUSIONS: Rural Mexican-American adolescent women may benefit from confidential identification and assessment of abuse history and risk and protective behaviors so that appropriate psychological treatment can accompany accessible medical treatment. The prevalence of risk behaviors and abuse among these women presents a need for development of behavioral interventions for risk reduction and promotion of health protective behaviors.

Prevention of gonorrhea and Chlamydia through behavioral intervention: results of a two-year controlled randomized trial in minority women.

BACKGROUND: Sexually transmitted disease (STD), including AIDS, disproportionately affects African-American and Hispanic women. GOAL: To evaluate efficacy of standard and enhanced (addition of optional support groups) gender- and culture-specific, small-group behavioral interventions, compared to interactive STD counseling, in high risk minority women for two years. METHODS: Women with a non-viral STD were treated and enrolled in a randomized trial. Follow-up screens and interviews occurred at 6 months, 1 year, 18 months (short interview, optional exam) and 2 years. The primary outcome was subsequent infection with chlamydia and/or gonorrhea. Secondary outcomes included risky sexual behaviors. We employed logistic regression based on intention-to-treat. RESULTS: Data from 775 women were included; the retention rate was 91%. Adjusted infection rates were higher in the controls in Year 1 (26.8%), Year 2 (23.1%), and cumulatively (39.8%) than in the enhanced (15.4%, P = 0.004; 14.8%, P < 0.03; 23.7%, P < 0.001, respectively) and standard (15.7%, P = 0.006; 14.7%, P = 0.03; 26.2%, P < 0.008, respectively) intervention arms at these time points. Enhanced-intervention women who opted to attend support groups (attendees) had the lowest adjusted infection rates in Year 1 (12.0%) and cumulatively (21.8%). Intervention women in general, but particularly attendees, were significantly less likely than controls to have repeat infections. Multiple partners and unprotected sex with an untreated or incompletely treated partner helped explain group differences in infection. CONCLUSIONS: Risk-reduction interventions significantly decreased both single and multiple infective episodes with chlamydia and/or gonorrhea and risky sexual behaviors in the two-year study period. Support-group attendance appeared to contribute additional risk reduction in Year 1.

Reduction in sexual risk behaviors and infection rates among African Americans and Mexican Americans.

BACKGROUND: Project SAFE, a gender- and culture-specific cognitive-behavioral intervention, was one of the few interventions to have demonstrated a significant reduction in sexually transmitted infections in a randomized, controlled trial. GOAL: We evaluated intervention efficacy in 379 Mexican Americans and 170 African Americans; and in a subset of 477 women, explored ethnic differences in the relationships over time between attitudes/beliefs about relationships, reported sexual behavior, and infection. STUDY DESIGN: Women were questioned intensively at baseline, 6, and 12 months. We used stratified analyses and multivariate regression to evaluate ethnic differences and the role of behavior in explaining ethnic differences in infection. RESULTS: African Americans had higher overall infection rates (29.0% vs. 18.3%) than Mexican Americans, but the intervention efficacy was similar (odds ratios, 0.58 and 0.54, respectively). African Americans reported more douching after sex, less mutual monogamy, and more rapid partner turnover. However, Mexican Americans appeared slightly more likely to have sex with an untreated partner, and there was no difference in risky sex. African Americans reported greater difficulty finding partners and reported attitudes more compatible with nonmonogamy. CONCLUSIONS: Despite substantial ethnic differences in attitudes/beliefs, behaviors, and infection rates, the intervention had a comparable impact on both Mexican American and African American.

Abused women and risk for pelvic inflammatory disease.

Mexican and African American women with sexually transmitted diseases (STDs) underwent targeted physical exams and questioning regarding sexual or physical abuse, current genitourinary symptomatology, and pelvic inflammatory disease (PID) risk behaviors to determine the relationship of sexual or physical abuse to the pathology of genitourinary symptoms affecting diagnoses of STDs and risk for PID. Bivariate comparisons found abused women reported more PID risk behaviors including earlier coitus, more sex partners, higher STD recurrence, and delayed health-seeking behavior. Multivariate comparisons found abused women were more likely to report pathologic genitourinary symptomatology than nonabused women. Clinicians made more presumptive diagnoses of PID for abused than for nonabused women upon physical examination. These findings indicate abused women are at high risk for PID. Its considerable impact on genitourinary symptomatology and risk for PID make assessment for abuse essential in clinical management of women with STDs and diagnosis of PID.

Minority adolescent women with sexually transmitted diseases and a history of sexual or physical abuse.

Life history methods were used to obtain a more in-depth understanding of the configuration of psychosocial and situational factors that are associated with high-risk sexual behavior among minority adolescent women with a history of sexual or physical abuse and sexually transmitted disease (STD), to facilitate development of behavioral risk-reduction interventions. Study participants ranged in age from 14 to 18 years; 19 were Mexican American and 11 were African American. Women were recruited from clinics in a metropolitan health district. Various constitutive patterns unfolded during interview analysis including "fearing," "trusting," and "being a woman." The study revealed the perceptions of an extremely high-risk population of adolescent women regarding their STD risk, the context of their sexual relationships, sexual risk behaviors, contraception, and STD prevention, screening, and treatment practices. Intervention strategies based upon these findings are described.

Behavioral interventions for prevention of sexually transmitted diseases in women: a physician's perspective.

Behavioral interventions to reduce STD risk in heterosexual women have been developed and tested in randomized, controlled trials. Some interventions have resulted in behavioral changes to reduce STD risk but either did not adequately study or did not affect actual rates of STD acquisition. Two studies have resulted in behavioral and STD rate changes using different intervention techniques (Project SAFE and Project RESPECT). Further studies are underway to improve efficacy and assist transfer to the community. Until interventions are more widely implemented, individual physicians can assist patients by providing a simple STD risk assessment and suggesting alternative behaviors to reduce risk.

Behaviors changed by intervention are associated with reduced STD recurrence: the importance of context in measurement.

BACKGROUND: Evaluations of STD/HIV interventions incorporating behavioral and biologic outcomes have not reported strong correspondence. GOAL: The goal of the study was to demonstrate that behaviors, measured comprehensively, are associated with infection and to delineate the behaviors responsible for reduced infection rates in Project SAFE (Sexual Awareness For Everyone). STUDY DESIGN: Follow-up data from an intervention trial were analyzed to determine: (1) study versus control differences in complex risk behaviors and (2) the overall relationship between these behaviors and infection status (chlamydia and/or gonorrhea), with use of multiple logistic regression. RESULTS: Lower infection rates among 249 women who received intervention (compared with 228 controls) were explained by reduced-risk status in 5 modifiable behaviors. The 0 to 12-month logistic regression model (including sex with untreated partner [OR = 5.6], lack of mutual monogamy [OR = 2.4], unsafe sex [OR = 1.9], rapid partner turnover [OR = 2.7], and douching after sex [OR = 1.9]) correctly predicted infection status for 75.3% of participants (71.8% of infected, 76.2% of uninfected). Women in nonmutually monogamous unions who had sex with partners who were untreated or incompletely treated were 13 times more likely to be infected than those who were monogamous and avoided sex with an untreated/incompletely treated partner. CONCLUSION: This intervention reduced infection rates by maintaining low-risk behaviors and changing high-risk behaviors. We elucidated the complex relationship between behavior and infection by incorporating context into variable conceptualization and considering several behaviors simultaneously.

Psychological distress among abused minority women with sexually transmitted diseases.

PURPOSE: To describe psychological distress among abused minority women with sexually transmitted diseases (STDs) and to identify needs for psychotherapeutic intervention for reduction in abuse, sexual risk behavior and STD. DATA SOURCES: A controlled randomized trial of the effects of a behavioral intervention on STD recurrence. Eligibility was limited to English speaking Mexican-American and African-American women with a current non-viral STD confirmed by laboratory testing (gonorrhea, chlamydia, syphilis or trichomonas). All eligible women who could be contacted were recruited from public-health clinics in San Antonio. T-tests, Chi square and correlation were used to analyze the data. CONCLUSIONS: Women with STD and a history of abuse reported more symptoms of current psychological distress than nonabused women. This psychological distress was present in all dimensions of the SCL-90-R, including somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. Increased current psychological distress and correlation was found not only for women with reports of sexual abuse but also forms of physical or psychological abuse. The majority of abuse was reportedly experienced during a relationship with a boyfriend or friend/acquaintance. IMPLICATIONS FOR PRACTICE: Abused women with STD may benefit from the identification and assessment of abuse history and psychological distress so that appropriate psychological treatment can accompany medical treatment. The prevalence of woman abuse within a population of women with STD mandates the inclusion of violence in STD prevention programs.

Rural woman abuse and sexually transmitted disease: an ethical analysis of clinical dilemmas.

Women who have experienced abuse are often offered individual and group psychotherapeutic interventions to help them overcome psychological aftereffects of abuse and avoid future abusive relationships. Clinical cases that are complicated by the existence of abuse and sexually transmitted diseases (STDs) often involve ethical issues concerning patient privacy and legitimate breaches of confidentiality that can potentially harm the individual. There is little known about the experiences of abused rural women with STDs, underscoring the need for modification of existing interventions for this patient population. This paper presents the application of an ethical framework to an actual case involving an abused rural woman with an STD that utilizes the concepts of casuiStry, or case-based reasoning. A methodological tool for ethical analysis of the clinical dilemmas involving evidence-based psychotherapeutic interventions for abused rural women with STDs is used to apply the concepts of casuistry to the development of the taxonomy of cases for clinical practice.