Sexually Transmitted Infection Rates and Patterns of Condom Use Among Young Adult Females at an Urban Emergency Department as Compared to College Students

Duane Eisaman, MD, PhD
Department of Emergency Medicine, Women’s Emergency Care Research Group, UPMC Magee-Women’s Hospital, Pittsburgh, PA 15213, USA; E-mail: eisamandm@upmc.edu

INTRODUCTION

It is reported that sexually transmitted infections (STIs) rapidly fell during shelter-in-place orders from March to April 2020¹ presumably due to limited person-to-person contact and thus limited sexual activity. Propaganda posted in public places by state health departments during the pandemic recommended masturbation and virtual platforms for sexting, with condoms and dental dams highly encouraged to keep safe.² Despite this recommendation, condom access and usage were unchanged.³ During this time frame and while resources for asymptomatic screening during preventative care visits rebooted for several months following, there was likely testing and treatment only for symptomatic individuals and only those who maintained disproportionate access to care. By the end of 2020, reported cases of gonorrhea and syphilis increased by 10% and 7%, respectively, when compared to 2019’s close. Often those with chlamydia have no signs and symptoms, with most cases identified through asymptomatic screening at routine preventative care visits. Therefore, it is likely chlamydia diagnosis and treatment were even more disproportionally affected during the pandemic, forwarding more long-term consequences for the individual (pelvic inflammatory disease, infertility, ectopic pregnancy, chronic pelvic pain) and for their partners and vertical transmission unknowingly spreading the disease.⁴ As a proxy, year-end data for 2020 demonstrated increases in the number of women reported with syphilis of all stages and congenital syphilis by 15.7% and 14.6%, respectively. This is superimposed upon a 128.3% and 235.1% increase in four years from 2016 alone.¹

Postulating reasons and actionable interventions to alter the continued rise in STIs is now a more important venture than ever before. Human behavior is complex and nuances in sexual behavior are likely even more so. Factors commonly associated with STI include social networks, testing, and contextual factors (i.e. social determinants). There is a higher burden among adolescents and young adults and by race-ethnicity with more affected subgroups other than non-Hispanic whites and non-Hispanic Asians. But within this, high school students in the United States and Britain reporting sex before thirteen years of age, four or more sexual partners, or currently sexually active decreased. Condom use in this population increased from 46.2-54.3%. Even income inequality, violent crime, and illicit drug use in adolescents remained even.^5,6,7 However, in men with STI risk factors (non-monogamy, men who have sex with men or in exchange for money/drugs, human immunodeficiency virus (HIV)), there were significant declines in condom use, especially those aged 15-19 and non-Hispanic whites. In contrast, trends in condom use among men with no STI risk factors remained stable or increased.⁸ It seems this is just one example of those at baseline higher-risk escalating that risk without barriers to contraception.

METHODS

 Participants/Materials

 The study was performed by surveying two distinct samples of females ages 18-22 from January to December 2022 who reported at least one-lifetime instance of sexual intercourse. The study size was determined by those who fit the inclusion criteria and were either seen in the emergency department (ED) or enrolled in the study during the January-December 2022 timeframe. No participants were excluded if the aforementioned inclusion criteria were met. The Qualtrics, Utah, USA survey was presented to the University group, and the emergency department survey was completed on paper. The emergency department group was patients at an urban emergency department located in a women’s hospital. These participants were surveyed during their stay in the emergency department in the privacy of their patient rooms. The participants in the college group were enrolled at a large urban-based public university. IRB approval was obtained from both the University and the hospital where the study took place. Participant informed consent was obtained before the start of the survey for both groups. There were no identifiers used and the participants had the opportunity to exit the survey at any time. Neither group received financial compensation for participating in this study. There were no risks to participation. The survey questions and responses can be found the Appendix. 

Covariates 

Demographic information included race (Black/African American, White, Asian/Pacific Islander, Hispanic/Latino, Native American), age, setting (urban ED or an urban university), educational status (any schooling up to General Educational Development (GED)/high school diploma, some college, college degree), sexual orientation (heterosexual, gay/lesbian, bisexual, other), and childhood household income.

Outcomes 

Several male partners, reported STI by type, condom use and provision by partner type and ethnicity, and condom failures and failure types were compared between the two study groups. When the likelihood of behavior was assessed, a Likert scale of 1-7 was used (1=very unlikely, 7=very likely).

Statistical Analyses 

Our analysis set included all survey respondents who consented and completed the demographic questions. Descriptive statistics were calculated overall and by group. Sample means and standard deviations were used for continuous measures, while sample proportions were used for categorical variables. Between-group comparisons were facilitated by two-sample t-tests and chi-square tests when appropriate; otherwise, non-parametric tests were used.

RESULTS

Eighty-nine women were surveyed: 48 participants from the emergency department group and 41 participants from the college group. Three individuals in the college group did not complete question 14. Twelve individuals in the ED group did not complete either questions 14 or 16. All responses were included in the dataset.

Seven out of forty-one (17.1%) university students and 21/48 (43.8%) of the ED patients reported a lifetime STI (p=0.034). The ED population had less family income on average. Education status was similar. On a scale from 1-very unlikely to 7-very likely, university students reported a likelihood of 3.63 and, ED patients 3.38 to use condoms in general (p=0.557), and if there is no condom available, university students reported a likelihood of 3.85 to proceed with sex versus ED patients reporting 3.93 (p=0.793). If it is a casual partner, 2.02 versus 2.37 (p=0.303), and if a long-term partner 4.05 versus 3.74 (p=0.359). Within the ED, African-American-identifying individuals reported similar condom use in general (3.54 versus 3.23, p=0.572). Those with lower childhood income trended towards more condom use, except for the lowest category (<$15,000). On average the risk per partner of contracting STI is 6 in the ED versus 8.2 in university students (p=0.2931) (Tables 1-4).

DISCUSSION AND CONCLUSION

Generally, people who are already at higher baseline risk for STI and other unwanted consequences of unprotected sex will engage in riskier behavior, perpetuating transmission. A study by Caruso et al³ in 2020 demonstrated that 50% of individuals not cohabitating or single discontinued contraceptives as opposed to 0% of married or who were cohabitating during the coronavirus disease-2019 (COVID-19) pandemic. However, 46% of those individuals who discontinued contraceptive use still engaged in sexual activity, resulting in 15% discovering an unplanned pregnancy and 15% of those unplanned pregnancies desiring a termination. Though as evidenced by our study and the several that attempted to characterize this phenomenon previously, we can presume those with known risky baseline factors (e.g. single, men who have sex with men (MSM), HIV, multiple partners, drug and alcohol use, etc.) will have a higher rate of STI, but determining a target at-risk population to intervene upon outside of and between these is not straightforward.

In general, it is thought that non-white race and lower income are risk factors for STI. Our ED population is made up of a higher proportion of individuals meeting these criteria and does report a higher STI rate. However, African-American-identifying individuals did not contribute to most of the cases and also used condoms more often. Likewise, those with lower childhood income used condoms more often except those at the lowest level (<$15,000). This is an interesting dynamic. To take it a step further, and to try to discover an intervenable at-risk group, we calculated “relative risk per partner”. This is a covariation between the number of reported partners and the rate of reported STI. The ED population (adjusted) risk per partner is 6 versus 8.2 in university students. Therefore, while the ED population can engage in the same frequency and barrier contraceptive behavior, they will be more likely to contract an STI. Perhaps earlier education regarding the use of barrier contraceptives in groups with high-risk per partner would help by focusing on high-risk males.

This study does have limitations due to the relatively small survey data set. Statistical significance would require a larger data set and may allow for more helpful covariation analysis. We did not address the perceived risk of STI directly, which may provide insight into whether individuals seem to engage in risky behavior despite informed consent or whether it is an intervenable knowledge gap. We also surveyed females only, limiting the look into to some of the highest-risk populations and ascertaining a male perspective. Male influence on partner’s behaviors and barrier contraceptives certainly has the potential to be a substantial component of decision-making for the female in their shared sexual encounter. Males also have an important role in the transmission of STI, particularly asymptomatically.^9,10 Lastly, the study does not address familial or cultural thoughts on birth control and barrier contraceptives, that anecdotally within our research team’s clinical encounters are an important influence on behavior.

In 2017, approximately 12% of married or in-union women all over the world already had an unmet need for contraception; this precedes the supply being severely affected by the pandemic, with manufacturing and transportation having been on lockdown.¹¹ Add this to a subset of the population who do not utilize potentially available resources, and STIs remain rampant.¹² Further research is necessary to determine actionable interventions for persons at higher-risk.

INSTITUTIONAL REVIEW BOARD PERMISSION

Yes.

CONSENT

Yes. 

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

1. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Disease Surveillance 2020. U.S. Department of Health and Human Services, 2020. Website. https://www.cdc.gov/std/statistics/2020/2020-SR-4-10-2023.pdf. Accessed June 13, 2016.

2. Abad-Santos A. The new rules of sex. Vox 2020. Website. https://www.vox.com/the-highlight/2020/6/17/21286933/sex-covid-coronavirus-dating-kissing-pandemic-safe. Accessed June 13, 2016.

3. Caruso S, Rapisarda AMC, Minona P. Sexual activity and contraceptive use during social distancing and self-isolation in the COVID-19 pandemic. Eur J Contracept Reprod Health Care. 2020; 25: 445-448. doi: 10.1080/13625187.2020.1830965

4. Manavi K. A review on infection with Chlamydia trachomatis. Best Pract Res Clin Obstet Gynaecol. 2006; 20: 941-951. doi: 10.1016/j.bpobgyn.2006.06.003

5. Scott RH, Wellings K, Lindberg L. Adolescent sexual activity, contraceptive use, and pregnancy in Britain and the US: A multidecade comparison. J Adolesc Health. 2020; 66: 582-588. doi: 10.1016/j.jadohealth.2019.11.310

6. Leichliter JS, Haderxhanaj LT, Obafemi OA. Increasing sexually transmitted infections among adolescents in the USA. Lancet Child Adolesc Health. 2021; 5: 609-611. doi: 10.1016/S2352-4642(21)00191-7

7. Stavridou A, Samiakou C, Kourti A, et al. Sexual activity in adolescents and young adults through COVID-19 pandemic. Children. 2021; 8: 577. doi: 10.3390/children8070577

8. Copen CE, Dittus PJ, Leichliter JS, Kumar S, Aral SO. Diverging trends in US male-female condom use by STI risk factors: A nationally representative study. Sex Transm Infect. 2022; 98: 50-52. doi: 10.1136/sextrans-2020-054642

9. Yu J, Tang W, Lau K, Chong L, Lo K. Asymptomatic urethral infection in male sexually transmitted disease clinic attendees. Int J STD AIDS. 2008; 19: 155-158. doi: 10.1258/ijsa.2007.007199

10. Takahashi S, Takeyama K, Miyamoto S, et al. Incidence of sexually transmitted infections in asymptomatic healthy young Japanese men. J Infect Chemother. 2005; 11: 270-273. doi: 10.1007/s10156-005-0411-1

11. Kumar N. COVID 19 era: A beginning of upsurge in unwanted pregnancies, unmet need for contraception and other women related issues. Eur J Contracept Reprod Health Care. 2020; 25(4): 323-325. doi: 10.1080/13625187.2020.1777398

12. Brown NE, Abebe A, Abebe K, Eisaman D. Determining factors associated with sexual behavior and undesired outcomes in urban, young, adult female populations: A comparative study. Women Health Open J. 2021; 7(1): 10-26. doi: 10.17140/WHOJ-7-142

13. Sexual Minority Assessment Research Team (SMART), The Williams Institute. Best Practices for Asking Questions about Sexual Orientation on Surveys. Web site. https://williamsinstitute.law.ucla.edu/wp-content/uploads/Best-Practices-SO-Surveys-Nov-2009.pdf. Published November 12, 2009. Accessed June 13, 2016.

14. Noll JG, Trickett PK, Putnam FW. A prospective investigation of the impact of childhood sexual abuse on the development of sexuality. J Consult Clin Psychol. 2003; 71(3): 575-586. doi: 10.1037/0022-006x.71.3.575

APPENDIX

Condom Use Survey

The complete survey as administered to participants is below. Sources of material use in this study are indicated following the question item by a superscript with the coinciding source at the end of the appendix. Survey items from outside sources in some instances were modified to fit the current study objectives. All other items were created by the researchers of the current study.

1. What is your current age (in years) _____?

2. Do you consider yourself to be: (Sexual Minority Assessment Research Team (SMART))¹³

a) Heterosexual or straight
b) Gay or lesbian
c) Bisexual
d) Other______

3. What is the highest degree or level of school you have completed? If currently enrolled, highest degree received.

a) Some high school
b) High school diploma or equivalent (for example: GED)
c) Some college credit (no degree) OR trade/technical/vocational training
d) College degree (Associate, Bachelor’s, Master’s, Professional, or Doctorate degree

4. In your childhood household, what was the approximate combined income of the providers

a) <$15,000
b) $15,000-$45,000
c) $45,000-$75,000
d) $75,000-$105,000
e) >$105,000

5. Ethnicity origin (or Race): Please specify your ethnicity. (May select more than one)

a. White
b. Hispanic or Latino
c. Black or African American
d. Native American or American Indian
e. Asian / Pacific Islander
f. Other

6. The ethnic origins of your male partners are similar to your ethnic origins: Always not racially similar Mostly not racially similar Somewhat not racially similar equal number of racially similar and non racially similar partners somewhat racially similar mostly racially similar always racially similar

7. How often do you use condoms during vaginal or anal intercourse?¹⁴
Never Seldom Sometimes About half the time Often Most of the time Always

8. If you and your partner are about to have penetrative sex however you do not have a condom, How likely will you still have sex without one?¹⁴
Very Unlikely Somewhat Unlikely Neither likely or unlikely Somewhat likely Very likely

A. If you have a new or casual partner?
Very Unlikely Somewhat Unlikely Neither likely or unlikely Somewhat likely Very likely

B. If you are in a long term relationship with this partner?¹⁴
Very Unlikely Somewhat Unlikely Neither likely or unlikely Somewhat likely Very likely

9. When you use a condom, who provides it?
You Your Partner Both

10. If your partner is a male, who do you think should provide a condom:
Male partner Female partner Both

11. Do you use anything else for birth control other than condoms? Y/N

If so what? _________

12. Have you had any issues with condoms breakage or slippage? Y/N

A. If you responded yes to the previous, do you think the condom failed because of a size issue?
Yes?No

B. If yes, was the condom too small or too big?
Too small Too big

13. Have you ever been diagnosed with any of the following?¹⁴
Select all that apply Trichomonas (Trich) Gonorrhea Chlamydia Pelvic inflammatory disease (PID)

14. Number of lifetime (voluntary) partners involving vaginal or anal sex: _______?¹⁴

15. If free condoms were available would you and your partner use them? Y/N