Reproductive health providers could help patients better understand their risks of both pregnancy and sexually transmitted infections (STIs) by asking nonjudgmental questions about their sexual activity, and offering testing for STIs and a vaccine for human papillomavirus (HPV).

For instance, women might believe they are safe from STIs because they are in a monogamous relationship. That is not always the case, says Kimberly R. McBride, PhD, MA, associate professor in the department of women’s and gender studies at the University of Toledo (OH).

“What they don’t understand is STIs often don’t show signs or symptoms,” McBride explains. “Someone might have one that’s been undiagnosed for a really long time, or their partner might have an STI.”

Minimize Stigma

Providers need to educate patients that contracting an STI is not necessarily a sign that their partner is not monogamous. HPV, herpes, gonorrhea, and chlamydia all have high rates of being asymptomatic. Unless someone is specifically tested for one of the infections, they will not know they are infected.

“Women who go into the clinic for their annual exam should be tested for STIs, and they often are not,” McBride says.

All it takes is for a provider to ask whether the patient would like to be tested for STIs. “When women go in for a gynecological exam, they may think they’re being tested for everything, and that’s not the case,” McBride says. “Offer to test them for STIs; make it an option that is like a normal option, saying, ‘If you’ve never been tested, this would be a good opportunity,’ and ‘This is a regular thing we do, and it’s not about you or your behavior.’”

This approach minimizes stigma and makes it easier for women to opt in, since they do not have to ask for STI testing, worrying about being judged by their provider.

“Think about young women who might feel stigma and shame. This gets around that barrier,” McBride says.

Be Nonjudgmental

It also is important to ask patients about all their sexual behaviors in as nonjudgmental a manner as possible. “Make sure you’re not making assumptions about what people do sexually,” McBride says. “People could be doing a variety of different things, and it’s always better for providers to introduce it because it normalizes it.”

For example, some young women will engage in anal intercourse as a contraceptive method or as a way to please partners when they are menstruating, McBride says.

“A lot of dynamics go into it,” she adds. “Some [engage in anal sex] for their own curiosity; some use it as a way to say they’re a virgin.”

Women tell investigators that they want their providers to make sure they are healthy and safe, but they are uncomfortable asking about risky sexual behaviors out of fear of being judged. “Providers should, at a minimum, assess patients for all behaviors,” McBride says.

For instance, anal sex is higher risk for STIs than vaginal sex. That should be discussed in a way that does not make a patient feel stigmatized. Anal STI testing also should be included if that is an activity in which the patient engages, particularly if condoms are not used.1

“For sexually active individuals, condoms are a primary method for preventing sexually transmitted diseases, and that’s the message for providers to be offering,” says Riley J. Steiner, PhD, MPH, health scientist on the adolescent and young adult team of the CDC’s Division of Reproductive Health. “We know that reported annual cases of STIs in the United States continue to climb, and we have increases each year over the past six years. We also know that in 2019, about half of STI cases were among adolescents and young adults [ages] 15-24 years.”2

Research suggests that stressing the STI prevention benefits of using condoms could be helpful.2

“That’s a message for providers to offer patients,” Steiner says. “For individuals at risk for STIs, family planning providers have an important role to play for preventing STIs in patients.”

Reproductive health providers can help patients understand that their use of long-acting reversible contraceptives (LARCs) and hormonal contraceptives can effectively prevent pregnancy, but they provide no protection against STIs, Steiner explains.

Providers could counsel patients that using condoms in addition to LARC or another birth control method would protect them from both pregnancy and STI transmission. Discussing condoms with patients can increase their use.

“Condoms are a highly effective option for preventing STIs and have a lot of benefits in terms of low cost and easy accessibility. They’re a valuable piece of the STI prevention portfolio,” Steiner says. “Even though there is a lot of complexity in terms of preventing both pregnancy and STIs, using condoms along with other methods of contraceptives do offer a straightforward message to clients.”

The larger point involves the value of offering reproductive health services that integrate pregnancy protection with protection from STIs. “We should start with those two goals and figure out the best prevention option for each one,” she says.

Condoms remain the chief STI prevention method, but patients also might want to discuss other methods, such as mutual monogamy and HIV prophylaxis.

“The point is, that if we think about integrating these two pieces of reproductive health, this can help providers think of the best strategies to meet patients’ goals,” Steiner says. “Helping them with strategies to reduce risk of infections is important for adolescents and young adults.”

REFERENCES

  1. Kay C, Kassel G. What to expect from anal STI testing — and why it’s a must. Healthline. April 29, 2020.
  2. Steiner RJ, Pampati S, Kortsmit KM, et al. Long-acting reversible contraception, condom use, and sexually transmitted infections: A systematic review and meta-analysis. Am J Prev Med 2021;61:750-760.