Discussing sexuality fosters sexual health: goal is greater than just prevention of sexually transmitted infections or unplanned pregnancies.

Every woman seeking reproductive health services brings her entire life's story with her. It is a story that providers should be prepared to listen to with respect because it may contain information vital to the woman's health and well-being.

Many aspects of a woman's life affect her reproductive health, including her relationship with her partner and her understanding of and beliefs about sexuality. Because of this, providers would be wise to consider discussing such issues with clients, says FHI researcher Dr. Patricia Bailey, whose work has included research on how contraception affects men's and women's quality of life. "The goal of such discussions would be to foster optimal sexual health, an aim that encompasses much more than just the prevention of sexually transmitted infections (STIs) or unplanned pregnancies," Dr. Bailey says.

The World Health Organization (WHO) defines sexual health as "the integration of the physical, emotional, intellectual, and social aspects of sexual being in ways that are enriching and that enhance personality, communication, and love." Furthermore, WHO states: "Fundamental to this concept are the right to sexual information and the right to pleasure." (1)

Violence, coercion, discrimination, fear, shame, guilt, false beliefs, and lack of knowledge about sexual issues are barriers to sexual health that many women throughout the world face. But providers can help by discussing in a respectful manner with clients aspects of their lives that may impede optimal sexual health.

"Providing quality reproductive health care is complex and involves an open dialogue between providers and clients about issues that traditionally may not have been discussed during medical consultations," Dr. Bailey says.

In-depth interviews with 15 gynecologists working in primary health care posts in Rio de Janeiro, Brazil, between 1993 and 1995, for instance, revealed that these doctors often found it difficult to discuss with female clients issues related to STIs and sexuality. It was particularly difficult to explain to a married woman that she had a genital infection and how she might have acquired it, since such an explanation implied marital infidelity.

"I tell her how she can avoid complications, but I do not get into how she might have been infected," said one of the gynecologists. "I do not think it would be good for her. We do not know how she got infected, and for her to get ideas ... I think it is best just to treat it."

When physicians in the study were asked what they typically said to a woman who had an STI, only half reported informing the client that her infection was transmitted through sexual contact.

"Look, I try to be neutral and not get involved in her private life," another physician said. "I have a very medical posture. I give her the results of the test and tell her if there is a disease ..."

In the same study, in-depth exit interviews with 42 women who had been diagnosed with chlamydia at primary health care posts in Rio de Janeiro where they sought gynecological and prenatal care revealed that only two of the women understood that their infection was transmitted through sexual contact. This suggests that their physicians had not discussed the subject with them. The 15 gynecologists interviewed for the study did not attend these women and, in fact, worked at other primary health care posts. But direct observation of gynecologists working at health posts where the 42 women were diagnosed revealed that those physiciaus' attitudes were similar to those of the 15 interviewed gynecologists, researchers reported. (2)

A clear explanation by a medical professional of the source of STIs is not sufficient to prevent infection, but it does serve as a foundation for the prevention of STIs, including HIV/AIDS. Such explanations can be especially important in settings like Brazil, where heterosexual intimate relations are the primary mode of HIV infection in women. (In Brazil, the female-to-male ratio of reported AIDS cases has increased from one female for every 28 males in 1985 to one female for every three males in 1995.)

In the same Brazilian study, even when clients persisted in attempting to discuss how they might have acquired an STI--such as through a partner's infidelity--some physicians avoided discussing the matter.

According to one doctor, "When the patient expresses suspicion of infidelity, I cut her off.... I say, look here, what is important is that you have a disease. Both you and your husband have to be treated, right?"

"But providers should be sensitive to women's concerns about infidelity," stresses FHI's Dr. Bailey, who helped coordinate an FHI Women's Studies Project from 1995 to 1996 that examined how contraceptive. use affects the sexuality, quality of life, and stability of couples in El Alto, Bolivia. Data for the study were collected from focus group discussions and in-depth interviews with 110 married women and 35 married men from El Alto.

In one focus group, several women discussed the impact of their husband's infidelities. "No, I don't like sex," a woman said. "He treats me badly and he goes with other women. And now he has these large pustules on him. I don't know what they are. He'll disappear for two or three nights and when I ask him, he always says he was with a friend." (3)

EXPLORING SEXUALITY, RELATIONSHIPS

Cultural beliefs about how active a woman should be in sexual relations can influence how a woman feels about her sexuality. One-half of the women interviewed in the El Alto study, for instance, said they did not consider it proper for married women to initiate sexual relations with their spouses. Many Bolivian men expressed the same view. However, the male focus group participants also agreed that one reason they become involved with extramarital lovers is because, unlike their wives, their girlfriends initiated sex. (4)

"Women need to know that it is normal to be an active participant in sex," Dr. Bailey says. "A sympathetic and caring provider who brings up the subject of sexuality with clients and creates an environment where it is comfortable for clients to talk about sex, can show clients that it is OK to think about and even articulate these things. Then women might be less nervous about bringing up the subject with their partners."

There is another key reason why providers would do well to consider talking with a woman about her sexuality and relationship with her partner: In some settings, intimate partner violence can limit a woman's access to health care or even prevent her from protecting herself against unplanned pregnancy or STIs.

A study from 1995 to 1996 of 6,632 married men living with their wives in Uttar Pradesh, India, found that abusive men were more likely than non-abusive men to have STI symptoms and to engage in extramarital sex. The study also found that unplanned pregnancies were more common in abusive relationships. (5)

"Women do not always have the power to make decisions about when they are going to have sex, how they are going to have sex, and what, if any, contraceptive method or disease-preventing method they are going to use," says Jane Schueller, FHI's Associate Director of Training and Education. "And, if a woman has a partner who has multiple partners outside their marriage, she is at greater risk of an STI or HIV/AIDS."

Even violence that has taken place many years ago can affect the reproductive health of a woman. Research has shown that women who grow up in abusive homes are at higher risk for unplanned pregnandes. (6)

That intimate partner violence is common in many settings is reflected in recent research. A 1995 population-based, household study of 488 women ages 15 to 49 years in Leon, Nicaragua, found that 40 percent had been physically abused by a partner at some point in their lives. (7) Another survey conducted in 1994 among 144 women in Sierra Leone, West Africa, found that two-thirds of the women had been physically abused by a partner and more than half had been forced by their partners to have sexual intercourse. The majority of study participants were recruited from family planning clinics and hospital clinic waiting rooms in Freetown and in the Northern Province, but some were also recruited from marketplaces, a refugee camp, and a teachers' college. (8) And a 1999 study conducted in the Purworejo District of Central Java, Indonesia, among a population-based sample of 765 married women who were recruited from a longitudinal study of health during pregnancy found that one in four had been physically or sexually abused by her husband. (9)

Intimate partner violence can affect a woman's reproductive health in many ways. In addition to being at increased risk of an STI and unplanned pregnancy, abused women are at higher risk for having an induced abortion, pre-term labor, low birth-weight babies, and various gynecological problems. For this reason, some experts feel that reproductive health clinics may be an ideal place to screen for intimate partner violence.

A 1997 FHI survey of 607 women from El Alto and La Paz, Bolivia, supports this premise. Nearly half of some 40 percent of women who reported experiencing intimate partner violence said they had visited a reproductive health clinic within the past year. (10)

"Reproductive health services are well-positioned to screen women for intimate partner violence," says Donna McCarraher, an FHI research associate who coordinated the FHI study. "But programs that intend to provide screening need to ensure that everyone in the clinic is thoroughly trained and committed to preventing intimate partner violence."

Program managers also need to evaluate whether staff have sufficient time to offer such services, she says. And policymakers and program managers need to define what to do if they identify victims of intimate partner violence through screening. If they plan to refer women for counseling or shelter, then program managers need to set up and maintain such a system, McCarraher says.

It is also important that programs be evaluated to find out if they are achieving their goals and really helping women. Finally, McCarraher stresses, even untrained providers working in settings where screening cannot be done can benefit from an understanding of how intimate partner violence affects reproductive health, including contraceptive use. Such an awareness can help providers monitor their behavior around clients.

"It is especially important that providers treat clients respectfully, maintain their confidentiality, and validate their experiences," McCarraher says. "In this way, providers can become part of the solution and not make a problem worse."

REFERENCES

(1.) World Health Organization. Education and Treatment in Human Sexuality The Training of Health Professionals. Technical Report Series 572. Geneva: World Health Organization, 1975.

(2.) Giffin K, Lowndes CM. Gender, sexuality, and the prevention of sexually transmissible diseases: a Brazilian study of clinical practice. Soc Sci Med 1999;48(3):283-92.

(3.) Camacho A, Rueda J, Ordonez E. Las Mujeres de El Alto se Descubren a si Mismas: Impacto de la Regulacion de la Fecundidad sobre la Estabilidad de la Pareja, la Sexualidad y la Calidad de Vida. Research Triangle Park, NC: Family Health International and Proyecto Integral de Salud, 1997.

(4.) Paulson S. Cultural bodies in Bolivia's gendered environment. Int J Sexuality Gender Stud 2000;5(2):125-40.

(5.) Martin SL, Kilgallen B, Tsui AO, et al. Sexual behaviors and reproductive health outcomes: associations with wife abuse in India. JAMA 1999;282(20):1967-72.

(6.) Dietz P, Spitz A, Anda R, et al. Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood. JAMA 1999,282(14):1359-64.

(7.) Ellsberg MC, Pena R, Herrera A, et al. Wife abuse among women of childbearing age in Nicaragua. Am J Public Health 1999;89(2):241-44.

(8.) Coker AL, Richter DL. Violence against women in Sierra Leone: frequency and correlates of intimate partner violence and forced sexual intercourse. Af J Reprod Health 1998;2(1):61-72.

(9.) Hakimi M, Hayati E, Marlinawati V, et al., eds. Silence for the Sake of Harmony: Domestic Violence and Women's Health in Central Java, Indonesia. Yogyakarta, Indonesia: CHN-RL GMU, Rifka Annisa Women's Crisis Center, Umea University, Women's Health Exchange, Program for Appropriate Technology in Health, 2001.

(10.) McCarraher D, Bailey P, Polo T, et al. Determinants of partner violence and the role of sexual and reproductive health services among women in Bolivia. Annual meeting of the American Public Health Association, Washington, DC, November 14-18, 1998.