Abstract
Purpose
A sexually transmitted infection (STI) diagnosis may profoundly change the meaning of adolescent women’s relationships, particularly when the relationship involves a shared child. This study explored the sexual, contraceptive, and emotional characteristics of sexual partners with whom adolescent women had and did not have children in the 3 months after the first STI diagnosis.
Methods
Adolescent women (n = 387; age: 14–17 years at enrollment) were tested quarterly for STI and completed partner-specific items on emotional and sexual relationship content. We used nonparametric statistics (SPSS/18.0) to compare these characteristics between partners with whom these adolescent women did (n = 20) or did not (n = 118) share a child.
Results
Rates of condom use at last sex, overall condom use, and condom insistence were lower with sexual partners involving shared children as compared with childless sexual partners. Relationship status, commitment to partner, and using no method of contraception were more common in parous sexual relationships as compared with nulliparous sexual relationships after an STI.
Conclusions
After an STI, adolescent women have different sexual risk behaviors with the fathers of their children, even after a signal event such as a recent STI diagnosis. Tailored counseling may specifically address the challenges of STI prevention with partners who have the unique status of being the “father of the baby.”
Keywords: Pregnant and parent adolescents, STI, Sexual relationships, Sexual and contraceptive behavior
It is well established that adolescent women’s condom use ranges from inconsistent to nonexistent in ongoing postpartum sexual relationships with the father of their children [1–3], contributing to an augmented likelihood of sexually transmitted infection (STI) acquisition [1,4–7]. The status ascribed to a sexual partner after pregnancy and birth may create a false sense of protection from future sexual vulnerability with that partner [8–10] as compared with childless sexual relationships, even in the face of an event signaling actual sexual risk such as a first STI diagnosis. Although previous research has examined relationship content and sexual decision-making before an STI, none has compared how parous and nulliparous sexual relationships differ after an STI, particularly in terms of any characteristic which may be associated with additional sexual risk. This study explored the sexual, contraceptive, and emotional characteristics of relationships involving and not involving children 3 months immediately after the first STI diagnosis.
Methods
Participants and study design
Data were part of a larger longitudinal 10-year cohort study (1999–2009) of sexual relationships, sexual behaviors, and STIs among young women (n = 387, age: 14–17 years at enrollment, 90% African American). Participants were from the patient population of three primary care adolescent health clinics in Indianapolis, serving lower- and middle-income families residing in areas with high rates of unintended pregnancy and STIs. As part of the study, young women were tested quarterly for STI and provided information on contraception, as well as partner-specific (up to five) information on sexual and emotional relationship content. Adolescent informed consent and permission from parent or legal guardian were obtained; research was approved by the Institutional Review Board of Indiana University/Purdue University at Indianapolis – Clarian.
Procedure
From the larger data set, we initially identified a subset of young women with no report of STI at enrollment, and retained quarterly reports provided by them in which they named only one sexual partner (69.3%: 3,573/5,151). From this subset, we marked the quarterly reports with an STI diagnosis (15%: 539/3,573), and indexed which of those occurred as the first STI with that sexual partner (70.5%: 380/539). From these observations, we retained those with whom a 90-day post-STI follow-up interview with the same partner was available (36.3%: 138/380), thus resulting in a single observation point per sexual partner for use in the current analysis. We further classified these partners as those with whom there was a shared child (n = 20) and those without a shared child (n = 118).
We adjusted for the small number of sexual partners with whom there was a shared child using nonparametric Mann–Whitney U tests to test for differences in means of sexual, contraceptive, and emotional relationship content, and Fisher’s exact tests was used for dichotomous variables (SPSS/18.0, IBM, Somers, NY; all at p< .05).
Measures
Partner-specific sexual behaviors included coital frequency, used a condom at last vaginal sex (no/yes), and ratio of condom-protected events.
Contraceptive behaviors included withdrawal (no/yes), rhythm method (no/yes), any hormonal method (no/yes), condoms and any hormonal method (no/yes), any barrier method (no/yes), and no method (no/yes).
Partner-specific relationship measures included relationship quality (5-item index; α = .92, e.g., “We have a strong emotional relationship” and “I think I am in love with him”), sexual satisfaction (5-item index, 7-point semantic differential items; α = .95, e.g., “Very bad to very good”), sexual communication (3-item index, 4-point Likert items, strongly disagree [SD] to strongly agree [SA]; α = .83, e.g., “It is easy to talk to him about using condoms” and “It is easy to talk to him about birth control”), condom use self-efficacy (4-item index, 4-point Likert items, SD to SA; α = .83, e.g., “He will have a condom if we want to have sex” and “He thinks condoms are good for protection”), relationship status (7-point Likert item: “don’t know well” to “boyfriend”), commitment to partner (single 4-point item, not all to completely: “How committed are you to this partner?”), sexual pressure (3-point Likert item, never to often: “Would he get mad at you if you didn’t want to have sex?”), condom insistence (3-point Likert item, SD to SA; “I won’t have sex unless we have a condom”).
Results
Descriptive statistics, mean/proportion comparisons, and statistical findings for each variable are provided in Table 1. Three months after an STI, rates of condom use at last sex, overall condom use, and condom insistence were lower in relationships with children as compared with relationships without children. Adolescent women with children also reported higher relationship status and higher commitment to partner after an STI diagnosis. Using no method of contraception or using withdrawal for contraception was more common in parous relationships. After an STI, parity was not associated with coital frequency, relationship quality, sexual satisfaction, sexual communication, condom self-efficacy, using the rhythm method, using hormonal contraception, using any barrier method, and dually using condoms with hormonal contraception.
Table 1.
Differences in the sexual, contraceptive, and emotional content between sexual partners with whom an adolescent women does (n = 20) and does not (n = 118) share a child, 3 months after a first STI diagnosis
| Variable | Nonfathers (n = 112) | Fathers (n = 20) | Mann–Whitney U test significance | Fisher’s exact test significance |
|---|---|---|---|---|
| Coital frequency (mean, SD) | 18.60 (32.23) | 21.95 (35.96) | .427 | — |
| Used a condom at last sex (yes) (N, %) | 56 (50.0) | 4 (20.0) | — | .013* |
| Ratio of condom-protected events (mean, SD) | .53 (.41) | .30 (.42) | .024* | — |
| Relationship status (mean, SD) | 3.95 (.66) | 4.41 (.68) | .005** | — |
| Relationship quality (mean, SD) | 19.75 (3.84) | 20.05 (3.47) | .688 | — |
| Sexual satisfaction (mean, SD) | 29.76 (6.87) | 32.00 (3.92) | .231 | — |
| Sexual communication (mean, SD) | 10.24 (1.66) | 10.52 (1.42) | .646 | — |
| Commitment to partner (mean, SD) | 3.29 (.96) | 3.76 (.83) | .044* | — |
| Sexual pressure | ||||
| Would get mad if we could not have sex (mean, SD) | 1.15 (.42) | 1.35 (.75) | .292 | — |
| Condom beliefs | ||||
| Condom use self-efficacy (mean, SD) | 14.88 (3.13) | 14.52 (3.16) | .851 | — |
| Condom insistence (mean, SD) | 2.53 (.91) | 2.10 (.87) | .048* | — |
| Contraceptive behaviors | ||||
| Used withdrawal (yes) (N, %) | 17 (15.1) | 13 (65.0) | — | .061*** |
| Used rhythm method (yes) (N, %) | 10 (8.9) | 1 (7.7) | — | .556 |
| Used any hormonal method (yes) (N, %) | 38 (33.9) | 4 (20.0) | — | .225 |
| Used condoms and hormonal method (yes) (N, %) | 27 (24.1) | 4 (20.0) | — | .878 |
| Used any barrier method (yes) (N, %) | 9 (8.1) | 2 (10.0) | — | .657 |
| Used no method (yes) (N, %) | 17 (15.1) | 7 (35.0) | — | .036* |
p < .05,
p < .01,
p < .10.
Discussion
The current project extends existing published data [1–3], suggesting that, after the first STI in a relationship, adolescent women used condom less frequently, insisted on condoms less often, and were more likely to use no method of contraception with sexual partners with whom there was a shared child as compared with sexual partners with whom there was no child. Our results also highlight the complexity of women’s relationships with the fathers of their children [8–10]; after an STI, sexual partners who had fathered a child were accorded higher relationship status and commitment with the mother of their children post-STI in comparison with the sexual partners in child-free sexual relationships.
Our findings may highlight the importance of tailored post-STI clinical sexual risk reduction and counseling among pregnant and postpartum adolescent women who are in sexual relationships with the fathers of their children. Providers can expect that the young women in these groups face unique challenges in terms of relationship dynamics, as well as with condom and contraceptive use. Understanding the content of these relationships may better help physicians anticipate the needs of pregnant and parenting adolescent women, specifically aiming at efforts to dispel their misperceptions related to future risk susceptibility, integrating sexual protection practices back into their relationships, as well as strengthening their relationship and negotiation skills with her sexual partner. Future research may add to these points, further clarifying, for example, at what point contraceptive and condom use decline with sexual partners when there is a shared child.
It is noteworthy that although the data were collected at a partner-specific level, the models presented here do not incorporate information about the couples’ histories before the STI or about timing of pregnancy relative to STI. Although these issues are of substantive interest, several methodological issues remain to be resolved. Future research may seek to compare the sexual decision-making trajectories of relationships involving and not involving children, as well as to establish how the timing and frequency of STI changes these trajectories. Additionally, the current study did not assess the effect of an STI in sexual relationships where there was no shared child but the adolescent woman had a child from another partner. The relative infrequency of this phenomenon precludes extensive analysis.
Acknowledgments
Sources of support: NIH grant numbers U19AI43924-06 and R01HD044387-03.
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