Journal of Midwifery & Women’s Health
www.jmwh.org
Original Research
The Effects of Intimate Partner Violence Duration on Individual and Partner-Related Sexual Risk Factors Among Women Holly B. Fontenot, PhD, RN, WHNP-BC, Heidi Collins Fantasia, PhD, RN, WHNP-BC, Terrence J. Lee-St. John, PhD, Melissa A. Sutherland, PhD, RN, FNP-BC
Introduction: Intimate partner violence (IPV) is associated with risk of sexually transmitted infections (STIs) and HIV among women, but less is known about mechanisms of this association and if length of relationship violence is a factor. The purpose of this study was to explore the relationship between the duration of IPV and both individual and partner-related sexual risk factors that may increase women’s risk for STIs and HIV. Methods: This was a secondary analysis of data collected from the medical records of 2000 women. Four distinct categories defined the duration of partner violence: violence in the past year only, past year and during the past 5 years, past year plus extending for greater than 5 years, and no past year violence but a history of partner violence. Logistic regression models were used to examine the associations between the duration of partner violence and individual sexual risk behaviors (eg, number of sexual partners, drug and/or alcohol use, anal sex) and partner-related sexual risk factors (eg, nonmonogamy, STI risk, condom nonuse). Results: Nearly 30% of the women in the study reported a history of partner violence during their lifetime. All of the individual risk factors, as well as partner-related risk factors, were significantly associated (P ⬍ .05) with partner violence and duration of violence. Discussion: The study findings extend the knowledge related to partner violence as a risk factor for STIs/HIV, highlighting the effects of partner violence duration on the health of women. Assessing for lifetime experiences of partner violence may improve outcomes for women and their families. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:67–73 Keywords: intimate partner violence, reproductive health, sexual risk factor
Address correspondence to Holly B. Fontenot, PhD, RN, WHNP-BC, Boston College, 140 Commonwealth Ave, Cushing Hall, Chestnut Hill MA 02467. E-mail: [email protected]
Approximately 24% of all new cases of HIV in the United States are diagnosed in women, and the primary route of transmission is heterosexual sex.11 Additionally, young women are biologically more susceptible and at greater risk for STI acquisition.13 Of the estimated 19 million new infections each year, 50% occur in young persons.14 For example, in 2010, the rate of chlamydial infections for women was approximately 610 cases per 100,000 females (over 2.5 times the rate for men) and among women aged 15 to 24 years who were screened at family planning clinics, the median state-specific chlamydia test positivity rate was 8.0%.14 Abstaining from oral, vaginal, and anal intercourse is the most effective way to prevent STIs, including HIV. Other prevention strategies include correct and consistent condom use, as well as limiting the number of lifetime sexual partners and exposure to STIs. Recent reports have documented a rise in heterosexual anal intercourse, and women participating in receptive anal intercourse without a condom are at greater risk for HIV acquisition.15 Unprotected anal intercourse has also been linked to IPV.16 In any sexual encounter there are STI/HIV risk behaviors that are controlled by the individual, as well as behaviors that are influenced by the partner. IPV has been linked to behaviors that place a woman at risk for HIV aquisition. Currently, little is known about partner-related sexual risk behaviors that are beyond the control of the individual woman. Existing research has also focused on IPV as a dichotomized construct, assessing whether women have or have not experienced IPV during their lifetime. The length and timing of IPV, behaviors controlled by the individual or the partner, and their relationship to reproductive and sexual health are underexplored.
1526-9523/09/$36.00 doi:10.1111/jmwh.12145
c 2014 by the American College of Nurse-Midwives
INTRODUCTION
Intimate partner violence (IPV) is a significant public health problem disproportionately affecting women. Although IPV is often associated with overt physical violence, it may also manifest as coercive control by one intimate partner that includes a range of abusive behaviors, such as physical and sexual violence, threats of physical or sexual violence, and emotional abuse in the context of physical or sexual violence.1 In the United States, it is estimated that approximately 25% of women will experience violence by an intimate partner during their lifetime.2 Disparities exist and rates of IPV that are greater than the national averages occur in specific populations. Researchers studying sexually transmitted infection (STI) and family planning clinic populations have documented IPV rates up to and greater than 50%.3, 4 The higher rates of IPV among women utilizing public STI/family planning clinics may be related to the increased negative reproductive and sexual health outcomes associated with women who seek care at these clinics.3, 5 Reproductive health consequences of IPV include STIs, unplanned pregnancy, condom nonuse, and sexual risktaking.6–9 IPV has also been identified as a risk factor for STI/HIV acquisition, possibly through mechanisms related to forced unprotected sex and other partner-related behaviors such as substance abuse, multiple partners, and coinfection with other STIs.10–12
67
✦ In any sexual encounter there are sexually transmitted infection (STI) and HIV risk behaviors that are controlled by the
individual, as well as behaviors that are influenced by the partner. ✦ Intimate partner violence (IPV) was significantly associated with individual sexual risk factors including: the number of
sexual partners during the past year, history of STIs, drug and/or alcohol use prior to intercourse, and anal sex. ✦ IPV was also significantly associated with partner-related sexual risk factors including: condom nonuse, partner non-
monogamy, and partner at risk for having an STI. ✦ The results from this study underscore the pervasiveness of violence in young women’s lives and highlight how screening
for partner violence in conjunction with STI and HIV risk behaviors is necessary.
The aim of this study was to explore the intersection of these significant public health problems and to examine the relationship between the duration of IPV and both individual and partner-related sexual risk factors that may increase women’s risk for STIs and HIV. This perspective has not been explored in previous research, addresses a gap in the current state of the science, and offers a unique contribution to the body of knowledge related to women’s health and IPV. CONCEPTUAL FRAMEWORK
A conceptual model developed by Coker6 and expanded by Miller et al3 that explores the relationship between IPV and sexual/reproductive health provided the theoretical framework for this study. Within the sexual risk literature, violence has been associated with sexual risk behaviors, including early initiation of sex,17–19 multiple partners,20 and drug and/or alcohol use prior to intercourse.21, 22 The expanded model describes the proposed mechanism of sexual coercion and its effect on women’s reproductive health and sexual risks. Briefly, coercive and controlling behavior by the male partner may include unprotected intercourse (condom nonuse), nonmonogamy, and partner at risk for STIs, thereby increasing women’s risk for STIs and HIV acquisition. Partnerrelated sexual risk factors may be coercive and have a direct negative effect on sexual health outcomes. Understanding these partner-influenced factors, in addition to individual risk factors and the impact of violence duration, may improve STI/HIV prevention. METHODS Design
This was a secondary data analysis of a retrospective study that examined data collected from women’s medical records from a group of 4 reproductive health clinics located in the northeastern United States. These 4 Title X clinics are part of the same organization; medical records are standardized across all sites. The clinics accept private insurance, but they also serve lower-income women and men on a fee-for-service slidingfee income scale for those who are uninsured or underinsured. The clinics provide family planning services and testing and treatment of STIs to women and men of all reproductive ages. Approval for the study was granted from the Boston College institutional review board and clinical agency. As this study examined existing data, informed consent was waived. Pre68
viously this data set was also used to explore the duration of partner violence as a predictor for contraceptive and reproductive patterns. A full description of this study is available.23 Sample
The data set extracted information from the medical records of 2000 women who had sought reproductive health services and had an annual gynecologic examination during the years 2006 to 2011. The data collection occurred between September 2010 and May 2011. For these analyses, data that pertained to history and timing of partner violence, individual sexual risks, and partner sexual risks were examined. Measures
Measures for demographics included age, race, ethnicity, marital status, employment, and education. All of the participating clinics utilized the same standardized history form at every visit to assess for partner violence. The 2 questions on this form that were combined to generate the experience of violence variable included: “Have you ever been abused/felt unsafe in a relationship: (physical/emotional/sexual) threats or violence?” and “Have you ever been forced to have sex when you didn’t want to?” The duration of the violence variable was then created by examining counts and timing of the woman’s reported partner violence that was identified in her summative medical record. This was calculated from clinician documentation written in response to a positive disclosure of violence, which included information on the timing of violence, duration of violence, current relationship safety status, and current/past social history. From the information available (patient history and clinician documentation in each patient’s medical record), 4 distinct categories were used to define and code the lifetime exposure to violence (duration of violence). These categories were: 1) partner violence in the past year only (recent exposure only); 2) partner violence in the past year and during the past 5 years only; 3) partner violence in the past year plus violence extending for greater than 5 years (longest duration); and 4) no partner violence in the past year but a previous history of partner violence (no current violence).23 Individual Sexual Risk Factors
Single items from the medical record used to assess for the individual sexual risk behaviors were the number of sexual Volume 59, No. 1, January/February 2014
Table 1. Experiences of Partner Violence in a Sample of Women Attending Family Planning Clinics (N = 2000)
n () No experiences of violence Experiences of violence Partner violence in past year only Partner violence in past year and during
1431 (72.5)
21.8 (6.5)
569 (28.5)
White, n (%)
1297 (64)
118 (20.7)
Single, n (%)
1753 (87.6)
55 (9.7) 30 (5.3)
extending for greater than 5 years No partner violence in past year but a
Demographics Age, mean (SD), y
the past 5 years only Partner violence in past year plus
Table 2. Demographic and Behavioral Characteristics in a Sample of Women Attending Family Planning Clinics (N = 2000)
Behavioral Characteristics Age at first intercourse, mean (SD), y
15.8 (2.06)
Number of reported sexual partners during the
2.08 (2.2)
past 12 months, mean (SD) 366 (64.3)
history of partner violence
partners in the past year, history of having an STI, drug and/or alcohol use prior to intercourse, and anal sex. Partner-Related Sexual Risk Factors
Single items from the medical record assessed the partnerrelated sexual risk behaviors of condom nonuse (“Did you use a condom the last time you had sex?”), partner nonmonogamy (“Do you have a partner who has other sexual partners?”), and partner at risk for having an STI (“Do you have a partner who is at risk for sexually transmitted diseases?”).
Report engaging in vaginal sex only, n (%)
704 (35.2)
Report engaging in vaginal and oral sex, n (%)
1025 (51.3)
Report engaging in vaginal, oral, and anal sex,
229 (11.5)
n (%) Report knowing their partner had multiple
780 (39)
other sexual partners, n (%) Report believing their partner is at risk for
717 (35.9)
STIs, n (%) Report not using a condom at last intercourse,
1518 (75.9)
n (%) Report using drugs and/or alcohol prior to sex,
732 (36.6)
n (%) Report having an abnormal Papanicolou
516 (25.8)
screening test, n (%) Analyses
Report having an HIV test in the past, n (%)
Descriptive statistics included percentages for categorical variables and the mean and standard deviation for continuous variables. Differences in individual and partner-related sexual risks were assessed via regression models based on exposure to the different categories of violence duration. Estimating a minimally detectable effect size equal to a 40% increase in the odds of engaging in a sexual risk behavior,20 and based on national IPV rates among women who attend family planning clinics,3, 4 we approximated 30% of the sampled women to obtain a history of IPV. The complete sample of 2000 records provides a power of 0.85 to determine a statistically significant (P value of ⬍ .05) difference between both individual and partner-related sexual risk factors among women exposed to violence and women without a history of violence. Potential confounding variables of age, race, ethnicity, education, marital status, and employment were controlled for in the final regression models. Statistical analyses were conducted using SPSS v.19 (IBM; Armonk, New York).
Report a history of bacterial vaginosis, n (%)
669 (33.5)
Report a history of Chlamydia trachomatis
415 (20.8)
RESULTS Descriptive Findings
Of the 2000 women in this data set, 64.9% (n = 1297) were white; the mean (SD) age was 21.8 (6.5) years; and the vast majority were single (87.6%, n = 1753). Nearly 30% of the sample (n = 569) indicated that they had experiences of partner violence during their lifetime (Table 1). In this analysis, approximately 98.4% of the sample reported ever having a sexual partner; the mean (SD) age at first intercourse was 15.8 (2.06). The mean (SD) number of Journal of Midwifery & Women’s Health r www.jmwh.org
1022 (51.1)
infection, n (%) Abbreviations: SD; standard deviation; STI, sexually transmitted infection.
reported sexual partners during the past 12 months was 2.08 (2.2). Thirty-nine percent reported knowing that their partner had multiple other sexual partners, and 35.9% identified that they had a partner who they felt was at risk for STIs. Despite these, 75.9% of the participants reported that they did not use condoms at their last sexual intercourse (Table 2). Multivariate Analysis Individual Sexual Risks
In adjusted logistic regression modeling, partner violence was significantly associated (P ⬍ .05) with individual sexual risk factors for the number of sexual partners during the past year, history of STIs, drug and/or alcohol use prior to intercourse, and anal sex. Compared to women with no lifetime experiences of violence, women in any of the violence categories reported a greater number of sexual partners during the past year, and women with a history of the longest duration of violence (partner violence in the past year plus extending for greater than 5 years) had the highest odds of having 2 or more partners. All categories of violence were also significantly associated with a history of STIs. Reporting partner violence in the past year plus extending for greater than 5 years increased 69
the odds of having a history of an STI by approximately 4 times (odds ratio [OR] 4.0; 95% confidence interval [CI], 3.4-24.6). Partner violence duration was also significantly associated with a history of using drugs and/or alcohol prior to sexual intercourse and engaging in anal sex; additionally, even a previous history of partner violence increased the probability of both of these sexual risk factors. Violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only all increased the odds for women using drugs and or alcohol prior to sex compared to women without a history of violence. Similarly, violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only all were significant predictors and increased the probability for engaging in anal sex (Table 3). Partner-Related Sexual Risks
Histories of partner violence duration were significantly associated (P ⬍ .05) with partner-related sexual risks (condom nonuse, partner nonmonogamy, partner at risk for having an STI). Violence during the past year only, the past 5 years, and previous history of violence only all increased the odds of having sex without a condom. All the varying levels of violence duration also increased the odds of having a partner who is known to have multiple other partners. Last, and with continued escalation of risk, partner violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only vastly increased the odds of the woman reporting that she believes her partner is at risk for STIs (see Table 4). DISCUSSION
The results from this study underscore the pervasiveness of violence in young women’s lives and highlight associations between partner violence and risk factors for STIs and HIV. This study was unique in that it approached STI/HIV risk factors by examining both individual factors, as well as those influenced by sexual partners. Also, the examination of the duration of violence in women’s lives was an important perspective that allowed for a greater understanding of risks related to length of exposure to partner violence. Understanding the effects of both recent and long-term exposures of violence may provide additional insights into risk behaviors and STI/HIV prevention. Our results support the findings from other studies,11, 19, 24 which suggest that violence is associated with sexual risk behaviors, including male partner-related behaviors that may be influencing female STI risks. Unlike previous research, our study examined the duration of violence and its influence on women’s STI/HIV risk. Partner violence was a significant predictor for both individual as well as partner-related STI/HIV risk factors; furthermore, patterns related to the levels of duration were noted in the analysis. For all the STI risks examined in this study, there was a consistent increase in the odds of the risk factors while the length of violence increased. Then, as partner violence ended, the odds of the risks also diminished. However, compared to women without a history of partner violence, the likelihood for experiencing any of the STI/HIV 70
sexual risk factors was consistently higher for women with a history of violence, even if the violence had ended. Compared to women without a current history of partner violence (past history of partner violence only), women who reported violence during the past year plus violence extending greater than 5 years (longest duration) had the greatest overall risk for STI acquisition. These women had the highest odds of having a partner with multiple partners, a partner with known risks for STIs, having a greater number of sexual partners during the past year, a previous history of an STI, using drugs or alcohol prior to sexual activity, and participating in anal intercourse. The length of violence exposure had an increased effect on multiple risk factors and together may accumulate to increase a woman’s overall risk for STIs and HIV, especially in the presence of condom nonuse, which for this sample was approximately 75%. Despite the increased probabilities of various STI/HIV risk factors for those with long-term histories of partner violence, even reported violence in the past year alone increased a woman’s risk for STI and HIV acquisition. Those with partner violence in the past year alone had a 5 to 8 times increased odds of reported partner-related risks and a 2 to 6 times increased odds of reported individual risk factors for STIs. This highlights the fact that screening for IPV is important, particularly among women of reproductive age. The high prevalence of partner violence in this sample strongly suggests the importance of addressing sexual risks in this population. Additionally, adolescents may be particularly at risk for IPV. The prevalence of violence within adolescent dating relationships has been well established in the literature.25 Researchers have also documented that this may be especially prevalent among adolescent women who have older male sexual partners, which may increase emotional manipulation, subtle coercion, and condom nonuse.9, 26 Although adolescents were not specifically examined as a subgroup in this study, health care providers who work with adolescent women should be aware of these risks when inquiring about relationships. Although condom nonuse was significantly associated with partner violence, in the total sample of young women— mostly in their early 20s—approximately 75% of the 2000 women reported not using condoms to protect themselves from STIs/HIV. It is interesting to note that although overall risk factors for STI and HIV acquisition were significantly associated with IPV, the overall rate of HIV in the total sample was extremely low (one case). Approximately half of the total sample had been tested for HIV during a clinic visit. Recommendations from the Centers for Disease Control and Prevention (CDC) include integrating HIV testing into routine care because half of all infections are diagnosed in health care settings.27 Previous research has demonstrated that women who are victims of IPV are twice as likely to seek HIV testing than women without a history of violence28 ; high rates of HIV screening were also seen in this sample. Although it is an individual choice to accept or decline testing, the overall risk behaviors of this sample highlight the importance of clinicians consistently providing HIV counseling and reviewing risk factors and their relation to HIV acquisition. Point-ofcare HIV counseling and testing may be another opportunity for IPV discussions with women when HIV risk factors are being reviewed. Volume 59, No. 1, January/February 2014
Table 3. Summary of Logistic Regression Analysis Association Between Violence Duration and Individual Sexual Risk Factorsa
Individual Sexual Risk Factors
OR ( CI)
P
6.6 (4.0-11.0)
⬍ .001
2 or more sexual partners in past year Partner violence in past year only
6.9 (3.2-15.1)
⬍ .001
13.0 (3.7-46.5)
⬍ .001
3.2 (2.4-4.2)
⬍ .001
Partner violence in past year only
2.5 (1.6-3.8)
⬍ .001
Past year partner violence and during the past 5 years
4.0 (3.9-15.6)
⬍ .001
Past year partner violence and during the past 5 years Past year partner violence plus extending for greater than 5 years No past year partner violence but a history History of STI
Past year partner violence plus extending for greater than 5 years
4.0 (3.4-24.6)
No past year partner violence but a history
3.0 (3.3-5.7)
⬍ .001
.008
Partner violence in past year only
5.1 (3.3-7.9)
⬍ .001
Past year partner violence and during the past 5 years
7.8 (3.9-15.6)
⬍ .001
Drug and/or alcohol use prior to sex
Past year partner violence plus extending for greater than 5 years
9.2 (3.4-24.6)
⬍ .001
No past year partner violence but a history
4.3 (3.3-5.7)
⬍ .001
2.4 (1.3-4.2)
.004
Anal intercourse Partner violence in past year only Past year partner violence and during the past 5 years Past year partner violence plus extending for greater than 5 years No past year partner violence but a history
6.0 (3.2-11.3)
⬍ .001
10.5 (4.7-23.6)
⬍ .001
3.9 (2.8-5.6)
⬍ .001
Abbreviations: CI, confidence interval; OR, odds ratio; STI, sexually transmitted infection. a Compared to women with no history of violence; analysis controlled for age, race, ethnicity, education, marital status, and employment.
Table 4. Summary of Logistic Regression Analysis Examining the Associations Between Violence Duration and Partner-Related Sexual Risk Factorsa
OR ( CI)
P
Partner violence in past year only
5.4 (2.7-10.8)
⬍.001
Past year partner violence and during the past 5 years
9.0 (2.2-37.7)
.003
Past year partner violence plus extending for greater than 5 years
5.5 (3.5-7.5)
.096
No past year partner violence but a history
5.6 (3.4-9.2)
⬍.001
Partner-Related Sexual Risk Ractors Last sexual intercourse without a condom
Partner with multiple partners 7.8 (5.0-12.2)
⬍.001
Past year partner violence and during the past 5 years
14.3 (6.3-32.3)
⬍.001
Past year partner violence plus extending for greater than 5 years
17.5 (5.1–60.1)
⬍.001
3.9 (3.0-5.1)
⬍ .001
8.6 (5.5-13.4)
⬍ .001
Past year partner violence and during the past 5 years
21.5 (9.0-51.2)
⬍ .001
Past year partner violence plus extending for greater than 5 years
23.9 (6.8-83.5)
⬍ .001
4.7 (3.6-6.2)
⬍ .001
Partner violence in past year only
No past year partner violence but a history Partner at risk for STI Partner violence in past year only
No past year partner violence but a history
Abbreviations: CI, confidence interval; OR, odds ratio; STI, sexually transmitted infection. a Compared to women with no history of violence; analysis controlled for age, race, ethnicity, education, marital status, and employment.
This study is not without limitations. Findings should be viewed accordingly. The nature of the retrospective chart review limits the examination of variables to only those existing in the medical record. For new patients, the duration of IPV incidence was established by what had been reported or charted in the medical record; therefore, this is a limitation Journal of Midwifery & Women’s Health r www.jmwh.org
for identifying duration. The notion of examining duration is a new concept and has not been fully validated. There is also the possibility of stigma related to the disclosure of IPV; therefore, this must be taken into consideration when considering disclosure of violence. Also, the cross-sectional design precludes drawing conclusions about the timing of the 71
partner violence in relation to the individual and partnerrelated STI risk factors. Additionally, some of the outcomes examined in this study occurred very infrequently. This reality, combined with the small sample sizes of 2 of the duration of violence groups (past year partner violence and during the past 5 years, past year partner violence plus extending for greater than 5 years), limited the statistical power for the associated coefficients, which in turn resulted in wide confidence intervals for the associated odds ratios. Though only statistically significant results are discussed, we note that the precision of the point estimates for some results is moderate at best. This study, however, has notable strengths. The sample represented data on 2000 women and was drawn from a standardized and comprehensive set of medical records from 4 reproductive health clinics with less than 5% missing data. In addition, care for these women was primarily provided by nurses and nurse practitioners. Last, the unique way in examining length of violence exposure allowed for evaluation of the effects of current, long-term, and past only exposures to violence on STI and HIV risk factors. Future research should focus on prospective designs to better evaluate the relationship between violence and STI risk factors, test interventions for both men and women to decrease violent and controlling behaviors, and mitigate STI individual and partner-related risk factors. Additional research should explore considering IPV as an independent risk factor for STI acquisition and testing protocols that use current/previous IPV as a rationale for STI screening among otherwise asymptomatic women. CLINICAL IMPLICATIONS
Health care clinicians who work in primary care, college health, adolescent health, obstetrics and gynecology, or in specialty STI/family planning clinics should be aware of the associations between both partner violence and risks for STI and HIV acquisition. The risk factors are multiple, may be partner-driven, and are exacerbated by a history of violence. In this sample, approximately 29% of women disclosed partner violence, which is slightly higher than the national average of 25%.2 Due to the high level of occurrence of partner violence among adolescents and young adults, screening for IPV should occur not only at routine preventative health visits but also during episodic STI and family planning visits. As part of more frequent screening, health care providers should consider how they inquire about IPV and also respond to positive disclosures of violence. Screening questions for IPV adapted from available instruments provide health care providers with standardized questions in a yes/no format.29, 30 However, these widely used tools do not assess the duration of violence. Given the results of this study, providers may also want to consider open-ended or additional questions to elicit information regarding timing and duration of violence. Last, IPV screening can also be an opportunity for education, including explanations for why we screen and a review of how violence affects the lives and health of women in many different ways, including an impact on STI/HIV risk. More frequent and open discussions related to the prevalence and risks of partner violence may increase opportunities for reflection about current relationships and may poten72
tially increase disclosure among those affected by violence. Within these discussions, clinicians must be aware of risk reduction activities that may be within the control of the individual woman such as reduction of drug and alcohol use prior to sexual activity, decreasing the number of lifetime sexual partners, and reduction in unprotected anal sex. Additionally, risks that are partner-related such as partner concurrency, partners who are at risk for STIs, and condom nonuse should be screened for and addressed if necessary. Information can be provided on condom negotiation and partner screening for STIs, especially for women who are unable to leave coercive and/or abusive relationships or who are unable to negotiate for condom use without a fear of escalation in violence. CONCLUSION
The experience of partner violence in young women’s relationships is prevalent and increases the risk for STI and HIV acquisition. Recent/short-term, chronic/long-term, and/or a past history of violence all significantly increase a woman’s probability of having numerous individual and partnerrelated STI risk factors. Health care clinicians can screen for and educate women and men about the impact that violent relationships may have on sexual health. Interventions are needed in the adolescent population to decrease or prevent partner violence. AUTHORS
Holly B. Fontenot, PhD, RN, WHNP-BC, is an Assistant Professor at Boston College, William F. Connell School of Nursing, and maintains clinical practice at the Sidney Borum Health Center in Boston, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an Assistant Professor at the University of Massachusetts Lowell, College of Health Sciences, School of Nursing, and maintains a clinical practice at Health Quarters in Beverly, MA. Terrence J. Lee-St. John, PhD, is a Senior Quantitative Researcher and Data Manager at the Center for Optimized Student Support at Boston College, Lynch School of Education. Melissa A. Sutherland, PhD, RN, WHNP-BC, is an Assistant Professor at Boston College, William F. Connell School of Nursing. CONFLICT OF INTEREST
Heidi Collins Fantasia is a member of the Women’s Health Advisory Board for Actavis Pharma, Inc., for which she receives travel and financial consideration. No other authors have any conflicts of interest to disclose. ACKNOWLEDGMENT
The American Nurses Foundation 2010 Gloria Smith Scholar was awarded to Melissa A. Sutherland. REFERENCES 1.Saltzman LE, Fanslow JL, McMahon PM, et al. Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 1999. Volume 59, No. 1, January/February 2014
2.Black MC, Breiding MJ. Adverse health conditions and health risk behaviors associated with intimate partner violence-United States, 2005. MMWR. 2008;57:113-117. 3.Miller E, Decker MR, McCauley HL, et al. Pregnancy coercion, intimate partner violence, and unintended pregnancy. Contrac. 2010;81:316-322. 4.Mittal M, Senn TE, Carey MP. Mediators of the relation between partner violence and sexual risk behavior among women attending a sexually transmitted disease clinic. Sex Trans Dis. 2011;38: 510-515. 5.Senn TE, Carey MP, Vanable PA. The intersection of violence, substance use, depression, and STDs: Testing of a syndemic pattern among patients attending an urban STD clinic. J Nat Med Assoc. 2010;102:614-620. 6.Coker AL. Does physical intimate partner violence affect sexual health? A systematic review. Trauma Vio Abuse. 2007;8:149-177. 7.McFarlane J, Malecha A, Watson K, et al. Intimate partner sexual assault against women: frequency, health consequences, and treatment outcomes. Obstet Gynecol. 2005;1051:99-108. 8.Sales JM, Salazar LF, Wingood GM, et al. The mediating role of partner communication skills on HIV/STD associated risk behaviors in young African American females with a history of sexual violence. Arch Ped Adol Med. 2008;1621:432-438. 9.Teitelman AM, Ratcliffe SJ, Morales-Aleman MN, et al. Sexual relationship power, intimate partner violence, and condom use among minority urban girls. J Interp Vio. 2008;231:1694-1712. 10.Centers for Disease Control and Prevention. HIV Among Women. 2011. Retrieved from http://www.cdc.gov/hiv/topics/women/index. htm. Accessed May 1, 2013. 11.Silverman JG, McCauley HL, Decker MR, et al. Coercive forms of sexual risk and associated violence perpetrated by male partners of female adolescents. Perspec Sex Repro Health. 2011;43:60-65. 12.Hess KL, Javanbakht M, Brown JM, et al. Intimate partner violence and sexually transmitted infections among young adult women. Sex Trans Dis. 2012;39:366-371. 13.Lee V, Tobin JM, Foley E. Relationship of cervical ectopy to chlamydia infection in young women. J Fam Plan Repro Health Care. 2006;32:104-106. 14.Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2010. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2011. 15.Baggaley R, White R, Boily M. HIV transmission risk through anal intercourse: Systematic review, meta-analysis and implications for HIV prevention. Intert J Epi. 2010;39:1048-1063. 16.Raj A, Reed E, Welles S, et al. Intimate partner violence perpetration, risky sexual behavior, and STI/HIV diagnosis among heterosexual African American men. Am J Men’s Health. 2008;2: 291-295.
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17.Silverman JG, Raj A, Mucci LA, et al. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy and suicidality. JAMA. 2001;286:572-579. 18.Upchurch DM, Kusunoki Y. Association between forced sex, sexual and protective practices, and sexually transmitted diseases among a national sample of adolescent girls. Wom Health Iss. 2004;14:75-84. 19.Raj A, Silverman JG, Amaro H. The relationship between sexual abuse and sexual risk among high school students: Findings from the 1997 Massachusetts Youth Risk Behavior Survey. Mat Child Health J. 2000;4:125-134. 20.Silverman JG, Raj A, Clements K. Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States. Pediatrics. 2004;107:e72-e76. 21.Bauer HM, Gibson P, Hernandez M, et al. Intimate partner violence and high-risk sexual behaviors among female patients with sexually transmitted diseases. Sex Trans Dis. 2002;29:411-416. 22.McDonnell KA, Gielen AC, O’Campo P. Does HIV status make a difference in the experience of lifetime abuse? Descriptions of lifetime abuse and its context among low-income urban women. J Urb Health. 2003;80:494-509. 23.Fantasia HC, Sutherland MA, Fontenot H, et al. Chronicity of partner violence, contraceptive patterns and pregnancy risk. Contrac. 2012;86:530-535. 24.Wingood GM, DiClemente RJ, McCree DH, et al. Dating violence and sexual health of black adolescent females. Pediatrics. 2001;107: e72(1-4). 25.Haynie DL, Farhat T, Brooks-Russell, A, et al. Dating violence perpetration and victimization among U.S. adolescents: Prevalence, patterns, and associations with health complaints and substance abuse. J Adol Health. 2013;53:194-201. 26.Volpe EM, Hardie TL, Cerulli C, et al. What’s age got to do with it? Partner age difference, power, intimate partner violence, and sexual risk in urban adolescents. J Inter Vio. 2013;28:2068-2087. 27.Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR14):1-17. 28.Brown MJ, Weitzen S, Lapane KL. Association between intimate partner violence and preventative screening among women. J Wom Health. 2013;00:1-6. 29.Soeken KL, McFarlane J, Parker B, Lominack MC. The abuse assessment screen: A clinical instrument to measure frequency, severity, and perpetrator of abuse against women. In: Campbell JC, ed. Empowering Survivors of Abuse: Health Care for Battered Women and Their Children. Thousand Oaks, CA: Sage Publications; 1998:195-203. 30.Basile K, Hertz M, Back S. Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings: Version 1. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control and Prevention; 2007.
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www.jmwh.org
Original Research
The Effects of Intimate Partner Violence Duration on Individual and Partner-Related Sexual Risk Factors Among Women Holly B. Fontenot, PhD, RN, WHNP-BC, Heidi Collins Fantasia, PhD, RN, WHNP-BC, Terrence J. Lee-St. John, PhD, Melissa A. Sutherland, PhD, RN, FNP-BC
Introduction: Intimate partner violence (IPV) is associated with risk of sexually transmitted infections (STIs) and HIV among women, but less is known about mechanisms of this association and if length of relationship violence is a factor. The purpose of this study was to explore the relationship between the duration of IPV and both individual and partner-related sexual risk factors that may increase women’s risk for STIs and HIV. Methods: This was a secondary analysis of data collected from the medical records of 2000 women. Four distinct categories defined the duration of partner violence: violence in the past year only, past year and during the past 5 years, past year plus extending for greater than 5 years, and no past year violence but a history of partner violence. Logistic regression models were used to examine the associations between the duration of partner violence and individual sexual risk behaviors (eg, number of sexual partners, drug and/or alcohol use, anal sex) and partner-related sexual risk factors (eg, nonmonogamy, STI risk, condom nonuse). Results: Nearly 30% of the women in the study reported a history of partner violence during their lifetime. All of the individual risk factors, as well as partner-related risk factors, were significantly associated (P ⬍ .05) with partner violence and duration of violence. Discussion: The study findings extend the knowledge related to partner violence as a risk factor for STIs/HIV, highlighting the effects of partner violence duration on the health of women. Assessing for lifetime experiences of partner violence may improve outcomes for women and their families. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:67–73 Keywords: intimate partner violence, reproductive health, sexual risk factor
Address correspondence to Holly B. Fontenot, PhD, RN, WHNP-BC, Boston College, 140 Commonwealth Ave, Cushing Hall, Chestnut Hill MA 02467. E-mail: [email protected]
Approximately 24% of all new cases of HIV in the United States are diagnosed in women, and the primary route of transmission is heterosexual sex.11 Additionally, young women are biologically more susceptible and at greater risk for STI acquisition.13 Of the estimated 19 million new infections each year, 50% occur in young persons.14 For example, in 2010, the rate of chlamydial infections for women was approximately 610 cases per 100,000 females (over 2.5 times the rate for men) and among women aged 15 to 24 years who were screened at family planning clinics, the median state-specific chlamydia test positivity rate was 8.0%.14 Abstaining from oral, vaginal, and anal intercourse is the most effective way to prevent STIs, including HIV. Other prevention strategies include correct and consistent condom use, as well as limiting the number of lifetime sexual partners and exposure to STIs. Recent reports have documented a rise in heterosexual anal intercourse, and women participating in receptive anal intercourse without a condom are at greater risk for HIV acquisition.15 Unprotected anal intercourse has also been linked to IPV.16 In any sexual encounter there are STI/HIV risk behaviors that are controlled by the individual, as well as behaviors that are influenced by the partner. IPV has been linked to behaviors that place a woman at risk for HIV aquisition. Currently, little is known about partner-related sexual risk behaviors that are beyond the control of the individual woman. Existing research has also focused on IPV as a dichotomized construct, assessing whether women have or have not experienced IPV during their lifetime. The length and timing of IPV, behaviors controlled by the individual or the partner, and their relationship to reproductive and sexual health are underexplored.
1526-9523/09/$36.00 doi:10.1111/jmwh.12145
c 2014 by the American College of Nurse-Midwives
INTRODUCTION
Intimate partner violence (IPV) is a significant public health problem disproportionately affecting women. Although IPV is often associated with overt physical violence, it may also manifest as coercive control by one intimate partner that includes a range of abusive behaviors, such as physical and sexual violence, threats of physical or sexual violence, and emotional abuse in the context of physical or sexual violence.1 In the United States, it is estimated that approximately 25% of women will experience violence by an intimate partner during their lifetime.2 Disparities exist and rates of IPV that are greater than the national averages occur in specific populations. Researchers studying sexually transmitted infection (STI) and family planning clinic populations have documented IPV rates up to and greater than 50%.3, 4 The higher rates of IPV among women utilizing public STI/family planning clinics may be related to the increased negative reproductive and sexual health outcomes associated with women who seek care at these clinics.3, 5 Reproductive health consequences of IPV include STIs, unplanned pregnancy, condom nonuse, and sexual risktaking.6–9 IPV has also been identified as a risk factor for STI/HIV acquisition, possibly through mechanisms related to forced unprotected sex and other partner-related behaviors such as substance abuse, multiple partners, and coinfection with other STIs.10–12
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✦ In any sexual encounter there are sexually transmitted infection (STI) and HIV risk behaviors that are controlled by the
individual, as well as behaviors that are influenced by the partner. ✦ Intimate partner violence (IPV) was significantly associated with individual sexual risk factors including: the number of
sexual partners during the past year, history of STIs, drug and/or alcohol use prior to intercourse, and anal sex. ✦ IPV was also significantly associated with partner-related sexual risk factors including: condom nonuse, partner non-
monogamy, and partner at risk for having an STI. ✦ The results from this study underscore the pervasiveness of violence in young women’s lives and highlight how screening
for partner violence in conjunction with STI and HIV risk behaviors is necessary.
The aim of this study was to explore the intersection of these significant public health problems and to examine the relationship between the duration of IPV and both individual and partner-related sexual risk factors that may increase women’s risk for STIs and HIV. This perspective has not been explored in previous research, addresses a gap in the current state of the science, and offers a unique contribution to the body of knowledge related to women’s health and IPV. CONCEPTUAL FRAMEWORK
A conceptual model developed by Coker6 and expanded by Miller et al3 that explores the relationship between IPV and sexual/reproductive health provided the theoretical framework for this study. Within the sexual risk literature, violence has been associated with sexual risk behaviors, including early initiation of sex,17–19 multiple partners,20 and drug and/or alcohol use prior to intercourse.21, 22 The expanded model describes the proposed mechanism of sexual coercion and its effect on women’s reproductive health and sexual risks. Briefly, coercive and controlling behavior by the male partner may include unprotected intercourse (condom nonuse), nonmonogamy, and partner at risk for STIs, thereby increasing women’s risk for STIs and HIV acquisition. Partnerrelated sexual risk factors may be coercive and have a direct negative effect on sexual health outcomes. Understanding these partner-influenced factors, in addition to individual risk factors and the impact of violence duration, may improve STI/HIV prevention. METHODS Design
This was a secondary data analysis of a retrospective study that examined data collected from women’s medical records from a group of 4 reproductive health clinics located in the northeastern United States. These 4 Title X clinics are part of the same organization; medical records are standardized across all sites. The clinics accept private insurance, but they also serve lower-income women and men on a fee-for-service slidingfee income scale for those who are uninsured or underinsured. The clinics provide family planning services and testing and treatment of STIs to women and men of all reproductive ages. Approval for the study was granted from the Boston College institutional review board and clinical agency. As this study examined existing data, informed consent was waived. Pre68
viously this data set was also used to explore the duration of partner violence as a predictor for contraceptive and reproductive patterns. A full description of this study is available.23 Sample
The data set extracted information from the medical records of 2000 women who had sought reproductive health services and had an annual gynecologic examination during the years 2006 to 2011. The data collection occurred between September 2010 and May 2011. For these analyses, data that pertained to history and timing of partner violence, individual sexual risks, and partner sexual risks were examined. Measures
Measures for demographics included age, race, ethnicity, marital status, employment, and education. All of the participating clinics utilized the same standardized history form at every visit to assess for partner violence. The 2 questions on this form that were combined to generate the experience of violence variable included: “Have you ever been abused/felt unsafe in a relationship: (physical/emotional/sexual) threats or violence?” and “Have you ever been forced to have sex when you didn’t want to?” The duration of the violence variable was then created by examining counts and timing of the woman’s reported partner violence that was identified in her summative medical record. This was calculated from clinician documentation written in response to a positive disclosure of violence, which included information on the timing of violence, duration of violence, current relationship safety status, and current/past social history. From the information available (patient history and clinician documentation in each patient’s medical record), 4 distinct categories were used to define and code the lifetime exposure to violence (duration of violence). These categories were: 1) partner violence in the past year only (recent exposure only); 2) partner violence in the past year and during the past 5 years only; 3) partner violence in the past year plus violence extending for greater than 5 years (longest duration); and 4) no partner violence in the past year but a previous history of partner violence (no current violence).23 Individual Sexual Risk Factors
Single items from the medical record used to assess for the individual sexual risk behaviors were the number of sexual Volume 59, No. 1, January/February 2014
Table 1. Experiences of Partner Violence in a Sample of Women Attending Family Planning Clinics (N = 2000)
n () No experiences of violence Experiences of violence Partner violence in past year only Partner violence in past year and during
1431 (72.5)
21.8 (6.5)
569 (28.5)
White, n (%)
1297 (64)
118 (20.7)
Single, n (%)
1753 (87.6)
55 (9.7) 30 (5.3)
extending for greater than 5 years No partner violence in past year but a
Demographics Age, mean (SD), y
the past 5 years only Partner violence in past year plus
Table 2. Demographic and Behavioral Characteristics in a Sample of Women Attending Family Planning Clinics (N = 2000)
Behavioral Characteristics Age at first intercourse, mean (SD), y
15.8 (2.06)
Number of reported sexual partners during the
2.08 (2.2)
past 12 months, mean (SD) 366 (64.3)
history of partner violence
partners in the past year, history of having an STI, drug and/or alcohol use prior to intercourse, and anal sex. Partner-Related Sexual Risk Factors
Single items from the medical record assessed the partnerrelated sexual risk behaviors of condom nonuse (“Did you use a condom the last time you had sex?”), partner nonmonogamy (“Do you have a partner who has other sexual partners?”), and partner at risk for having an STI (“Do you have a partner who is at risk for sexually transmitted diseases?”).
Report engaging in vaginal sex only, n (%)
704 (35.2)
Report engaging in vaginal and oral sex, n (%)
1025 (51.3)
Report engaging in vaginal, oral, and anal sex,
229 (11.5)
n (%) Report knowing their partner had multiple
780 (39)
other sexual partners, n (%) Report believing their partner is at risk for
717 (35.9)
STIs, n (%) Report not using a condom at last intercourse,
1518 (75.9)
n (%) Report using drugs and/or alcohol prior to sex,
732 (36.6)
n (%) Report having an abnormal Papanicolou
516 (25.8)
screening test, n (%) Analyses
Report having an HIV test in the past, n (%)
Descriptive statistics included percentages for categorical variables and the mean and standard deviation for continuous variables. Differences in individual and partner-related sexual risks were assessed via regression models based on exposure to the different categories of violence duration. Estimating a minimally detectable effect size equal to a 40% increase in the odds of engaging in a sexual risk behavior,20 and based on national IPV rates among women who attend family planning clinics,3, 4 we approximated 30% of the sampled women to obtain a history of IPV. The complete sample of 2000 records provides a power of 0.85 to determine a statistically significant (P value of ⬍ .05) difference between both individual and partner-related sexual risk factors among women exposed to violence and women without a history of violence. Potential confounding variables of age, race, ethnicity, education, marital status, and employment were controlled for in the final regression models. Statistical analyses were conducted using SPSS v.19 (IBM; Armonk, New York).
Report a history of bacterial vaginosis, n (%)
669 (33.5)
Report a history of Chlamydia trachomatis
415 (20.8)
RESULTS Descriptive Findings
Of the 2000 women in this data set, 64.9% (n = 1297) were white; the mean (SD) age was 21.8 (6.5) years; and the vast majority were single (87.6%, n = 1753). Nearly 30% of the sample (n = 569) indicated that they had experiences of partner violence during their lifetime (Table 1). In this analysis, approximately 98.4% of the sample reported ever having a sexual partner; the mean (SD) age at first intercourse was 15.8 (2.06). The mean (SD) number of Journal of Midwifery & Women’s Health r www.jmwh.org
1022 (51.1)
infection, n (%) Abbreviations: SD; standard deviation; STI, sexually transmitted infection.
reported sexual partners during the past 12 months was 2.08 (2.2). Thirty-nine percent reported knowing that their partner had multiple other sexual partners, and 35.9% identified that they had a partner who they felt was at risk for STIs. Despite these, 75.9% of the participants reported that they did not use condoms at their last sexual intercourse (Table 2). Multivariate Analysis Individual Sexual Risks
In adjusted logistic regression modeling, partner violence was significantly associated (P ⬍ .05) with individual sexual risk factors for the number of sexual partners during the past year, history of STIs, drug and/or alcohol use prior to intercourse, and anal sex. Compared to women with no lifetime experiences of violence, women in any of the violence categories reported a greater number of sexual partners during the past year, and women with a history of the longest duration of violence (partner violence in the past year plus extending for greater than 5 years) had the highest odds of having 2 or more partners. All categories of violence were also significantly associated with a history of STIs. Reporting partner violence in the past year plus extending for greater than 5 years increased 69
the odds of having a history of an STI by approximately 4 times (odds ratio [OR] 4.0; 95% confidence interval [CI], 3.4-24.6). Partner violence duration was also significantly associated with a history of using drugs and/or alcohol prior to sexual intercourse and engaging in anal sex; additionally, even a previous history of partner violence increased the probability of both of these sexual risk factors. Violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only all increased the odds for women using drugs and or alcohol prior to sex compared to women without a history of violence. Similarly, violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only all were significant predictors and increased the probability for engaging in anal sex (Table 3). Partner-Related Sexual Risks
Histories of partner violence duration were significantly associated (P ⬍ .05) with partner-related sexual risks (condom nonuse, partner nonmonogamy, partner at risk for having an STI). Violence during the past year only, the past 5 years, and previous history of violence only all increased the odds of having sex without a condom. All the varying levels of violence duration also increased the odds of having a partner who is known to have multiple other partners. Last, and with continued escalation of risk, partner violence during the past year only, the past 5 years, extending greater than 5 years, and previous history of violence only vastly increased the odds of the woman reporting that she believes her partner is at risk for STIs (see Table 4). DISCUSSION
The results from this study underscore the pervasiveness of violence in young women’s lives and highlight associations between partner violence and risk factors for STIs and HIV. This study was unique in that it approached STI/HIV risk factors by examining both individual factors, as well as those influenced by sexual partners. Also, the examination of the duration of violence in women’s lives was an important perspective that allowed for a greater understanding of risks related to length of exposure to partner violence. Understanding the effects of both recent and long-term exposures of violence may provide additional insights into risk behaviors and STI/HIV prevention. Our results support the findings from other studies,11, 19, 24 which suggest that violence is associated with sexual risk behaviors, including male partner-related behaviors that may be influencing female STI risks. Unlike previous research, our study examined the duration of violence and its influence on women’s STI/HIV risk. Partner violence was a significant predictor for both individual as well as partner-related STI/HIV risk factors; furthermore, patterns related to the levels of duration were noted in the analysis. For all the STI risks examined in this study, there was a consistent increase in the odds of the risk factors while the length of violence increased. Then, as partner violence ended, the odds of the risks also diminished. However, compared to women without a history of partner violence, the likelihood for experiencing any of the STI/HIV 70
sexual risk factors was consistently higher for women with a history of violence, even if the violence had ended. Compared to women without a current history of partner violence (past history of partner violence only), women who reported violence during the past year plus violence extending greater than 5 years (longest duration) had the greatest overall risk for STI acquisition. These women had the highest odds of having a partner with multiple partners, a partner with known risks for STIs, having a greater number of sexual partners during the past year, a previous history of an STI, using drugs or alcohol prior to sexual activity, and participating in anal intercourse. The length of violence exposure had an increased effect on multiple risk factors and together may accumulate to increase a woman’s overall risk for STIs and HIV, especially in the presence of condom nonuse, which for this sample was approximately 75%. Despite the increased probabilities of various STI/HIV risk factors for those with long-term histories of partner violence, even reported violence in the past year alone increased a woman’s risk for STI and HIV acquisition. Those with partner violence in the past year alone had a 5 to 8 times increased odds of reported partner-related risks and a 2 to 6 times increased odds of reported individual risk factors for STIs. This highlights the fact that screening for IPV is important, particularly among women of reproductive age. The high prevalence of partner violence in this sample strongly suggests the importance of addressing sexual risks in this population. Additionally, adolescents may be particularly at risk for IPV. The prevalence of violence within adolescent dating relationships has been well established in the literature.25 Researchers have also documented that this may be especially prevalent among adolescent women who have older male sexual partners, which may increase emotional manipulation, subtle coercion, and condom nonuse.9, 26 Although adolescents were not specifically examined as a subgroup in this study, health care providers who work with adolescent women should be aware of these risks when inquiring about relationships. Although condom nonuse was significantly associated with partner violence, in the total sample of young women— mostly in their early 20s—approximately 75% of the 2000 women reported not using condoms to protect themselves from STIs/HIV. It is interesting to note that although overall risk factors for STI and HIV acquisition were significantly associated with IPV, the overall rate of HIV in the total sample was extremely low (one case). Approximately half of the total sample had been tested for HIV during a clinic visit. Recommendations from the Centers for Disease Control and Prevention (CDC) include integrating HIV testing into routine care because half of all infections are diagnosed in health care settings.27 Previous research has demonstrated that women who are victims of IPV are twice as likely to seek HIV testing than women without a history of violence28 ; high rates of HIV screening were also seen in this sample. Although it is an individual choice to accept or decline testing, the overall risk behaviors of this sample highlight the importance of clinicians consistently providing HIV counseling and reviewing risk factors and their relation to HIV acquisition. Point-ofcare HIV counseling and testing may be another opportunity for IPV discussions with women when HIV risk factors are being reviewed. Volume 59, No. 1, January/February 2014
Table 3. Summary of Logistic Regression Analysis Association Between Violence Duration and Individual Sexual Risk Factorsa
Individual Sexual Risk Factors
OR ( CI)
P
6.6 (4.0-11.0)
⬍ .001
2 or more sexual partners in past year Partner violence in past year only
6.9 (3.2-15.1)
⬍ .001
13.0 (3.7-46.5)
⬍ .001
3.2 (2.4-4.2)
⬍ .001
Partner violence in past year only
2.5 (1.6-3.8)
⬍ .001
Past year partner violence and during the past 5 years
4.0 (3.9-15.6)
⬍ .001
Past year partner violence and during the past 5 years Past year partner violence plus extending for greater than 5 years No past year partner violence but a history History of STI
Past year partner violence plus extending for greater than 5 years
4.0 (3.4-24.6)
No past year partner violence but a history
3.0 (3.3-5.7)
⬍ .001
.008
Partner violence in past year only
5.1 (3.3-7.9)
⬍ .001
Past year partner violence and during the past 5 years
7.8 (3.9-15.6)
⬍ .001
Drug and/or alcohol use prior to sex
Past year partner violence plus extending for greater than 5 years
9.2 (3.4-24.6)
⬍ .001
No past year partner violence but a history
4.3 (3.3-5.7)
⬍ .001
2.4 (1.3-4.2)
.004
Anal intercourse Partner violence in past year only Past year partner violence and during the past 5 years Past year partner violence plus extending for greater than 5 years No past year partner violence but a history
6.0 (3.2-11.3)
⬍ .001
10.5 (4.7-23.6)
⬍ .001
3.9 (2.8-5.6)
⬍ .001
Abbreviations: CI, confidence interval; OR, odds ratio; STI, sexually transmitted infection. a Compared to women with no history of violence; analysis controlled for age, race, ethnicity, education, marital status, and employment.
Table 4. Summary of Logistic Regression Analysis Examining the Associations Between Violence Duration and Partner-Related Sexual Risk Factorsa
OR ( CI)
P
Partner violence in past year only
5.4 (2.7-10.8)
⬍.001
Past year partner violence and during the past 5 years
9.0 (2.2-37.7)
.003
Past year partner violence plus extending for greater than 5 years
5.5 (3.5-7.5)
.096
No past year partner violence but a history
5.6 (3.4-9.2)
⬍.001
Partner-Related Sexual Risk Ractors Last sexual intercourse without a condom
Partner with multiple partners 7.8 (5.0-12.2)
⬍.001
Past year partner violence and during the past 5 years
14.3 (6.3-32.3)
⬍.001
Past year partner violence plus extending for greater than 5 years
17.5 (5.1–60.1)
⬍.001
3.9 (3.0-5.1)
⬍ .001
8.6 (5.5-13.4)
⬍ .001
Past year partner violence and during the past 5 years
21.5 (9.0-51.2)
⬍ .001
Past year partner violence plus extending for greater than 5 years
23.9 (6.8-83.5)
⬍ .001
4.7 (3.6-6.2)
⬍ .001
Partner violence in past year only
No past year partner violence but a history Partner at risk for STI Partner violence in past year only
No past year partner violence but a history
Abbreviations: CI, confidence interval; OR, odds ratio; STI, sexually transmitted infection. a Compared to women with no history of violence; analysis controlled for age, race, ethnicity, education, marital status, and employment.
This study is not without limitations. Findings should be viewed accordingly. The nature of the retrospective chart review limits the examination of variables to only those existing in the medical record. For new patients, the duration of IPV incidence was established by what had been reported or charted in the medical record; therefore, this is a limitation Journal of Midwifery & Women’s Health r www.jmwh.org
for identifying duration. The notion of examining duration is a new concept and has not been fully validated. There is also the possibility of stigma related to the disclosure of IPV; therefore, this must be taken into consideration when considering disclosure of violence. Also, the cross-sectional design precludes drawing conclusions about the timing of the 71
partner violence in relation to the individual and partnerrelated STI risk factors. Additionally, some of the outcomes examined in this study occurred very infrequently. This reality, combined with the small sample sizes of 2 of the duration of violence groups (past year partner violence and during the past 5 years, past year partner violence plus extending for greater than 5 years), limited the statistical power for the associated coefficients, which in turn resulted in wide confidence intervals for the associated odds ratios. Though only statistically significant results are discussed, we note that the precision of the point estimates for some results is moderate at best. This study, however, has notable strengths. The sample represented data on 2000 women and was drawn from a standardized and comprehensive set of medical records from 4 reproductive health clinics with less than 5% missing data. In addition, care for these women was primarily provided by nurses and nurse practitioners. Last, the unique way in examining length of violence exposure allowed for evaluation of the effects of current, long-term, and past only exposures to violence on STI and HIV risk factors. Future research should focus on prospective designs to better evaluate the relationship between violence and STI risk factors, test interventions for both men and women to decrease violent and controlling behaviors, and mitigate STI individual and partner-related risk factors. Additional research should explore considering IPV as an independent risk factor for STI acquisition and testing protocols that use current/previous IPV as a rationale for STI screening among otherwise asymptomatic women. CLINICAL IMPLICATIONS
Health care clinicians who work in primary care, college health, adolescent health, obstetrics and gynecology, or in specialty STI/family planning clinics should be aware of the associations between both partner violence and risks for STI and HIV acquisition. The risk factors are multiple, may be partner-driven, and are exacerbated by a history of violence. In this sample, approximately 29% of women disclosed partner violence, which is slightly higher than the national average of 25%.2 Due to the high level of occurrence of partner violence among adolescents and young adults, screening for IPV should occur not only at routine preventative health visits but also during episodic STI and family planning visits. As part of more frequent screening, health care providers should consider how they inquire about IPV and also respond to positive disclosures of violence. Screening questions for IPV adapted from available instruments provide health care providers with standardized questions in a yes/no format.29, 30 However, these widely used tools do not assess the duration of violence. Given the results of this study, providers may also want to consider open-ended or additional questions to elicit information regarding timing and duration of violence. Last, IPV screening can also be an opportunity for education, including explanations for why we screen and a review of how violence affects the lives and health of women in many different ways, including an impact on STI/HIV risk. More frequent and open discussions related to the prevalence and risks of partner violence may increase opportunities for reflection about current relationships and may poten72
tially increase disclosure among those affected by violence. Within these discussions, clinicians must be aware of risk reduction activities that may be within the control of the individual woman such as reduction of drug and alcohol use prior to sexual activity, decreasing the number of lifetime sexual partners, and reduction in unprotected anal sex. Additionally, risks that are partner-related such as partner concurrency, partners who are at risk for STIs, and condom nonuse should be screened for and addressed if necessary. Information can be provided on condom negotiation and partner screening for STIs, especially for women who are unable to leave coercive and/or abusive relationships or who are unable to negotiate for condom use without a fear of escalation in violence. CONCLUSION
The experience of partner violence in young women’s relationships is prevalent and increases the risk for STI and HIV acquisition. Recent/short-term, chronic/long-term, and/or a past history of violence all significantly increase a woman’s probability of having numerous individual and partnerrelated STI risk factors. Health care clinicians can screen for and educate women and men about the impact that violent relationships may have on sexual health. Interventions are needed in the adolescent population to decrease or prevent partner violence. AUTHORS
Holly B. Fontenot, PhD, RN, WHNP-BC, is an Assistant Professor at Boston College, William F. Connell School of Nursing, and maintains clinical practice at the Sidney Borum Health Center in Boston, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an Assistant Professor at the University of Massachusetts Lowell, College of Health Sciences, School of Nursing, and maintains a clinical practice at Health Quarters in Beverly, MA. Terrence J. Lee-St. John, PhD, is a Senior Quantitative Researcher and Data Manager at the Center for Optimized Student Support at Boston College, Lynch School of Education. Melissa A. Sutherland, PhD, RN, WHNP-BC, is an Assistant Professor at Boston College, William F. Connell School of Nursing. CONFLICT OF INTEREST
Heidi Collins Fantasia is a member of the Women’s Health Advisory Board for Actavis Pharma, Inc., for which she receives travel and financial consideration. No other authors have any conflicts of interest to disclose. ACKNOWLEDGMENT
The American Nurses Foundation 2010 Gloria Smith Scholar was awarded to Melissa A. Sutherland. REFERENCES 1.Saltzman LE, Fanslow JL, McMahon PM, et al. Intimate Partner Violence Surveillance Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 1999. Volume 59, No. 1, January/February 2014
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