What are the Risk Factors for Acquiring an STD?
Women are at greater risk of acquiring an STD than men, because anatomical differences make these diseases more easily transmissible to (as well as more difficult to diagnose in) women. (20) In a single act of unprotected intercourse with an infected partner, for example, a woman is twice as likely as a man to contract gonorrhea, chlamydia, chancroid or hepatitis B, and half again as likely to acquire syphilis. The risk of acquiring gonorrhea or chlamydia, which cause serious, lifelong problems for many women, is especially high: Women have a 50% chance of acquiring gonorrhea and a 40% likelihood of contracting chlamydia during a single act of unprotected intercourse with an infected partner. (37)
Teenage women may be even more susceptible to a sexually transmitted infection than older women. Young women are likely to have fewer protective antibodies to STDs (38) and a biologically immature cervix (38,39,40)--factors that appear to increase their risk of cervical infection.
An active STD infection can leave both men and women more susceptible to coinfections. Individuals who have genital ulcers as a result of syphilis, herpes or chancroid, as well as persons with common nonulcerative infections, such as chlamydia, gonorrhea and trichomoniasis, have a 3-5 times greater risk than persons without an active infection of contracting HIV exposed to that virus. HIV infection, on the other hand, appears to increase susceptibility to other sexually transmitted infections by compromising an individual's immune system and making treatment of these diseases more difficult. (16)
Biological factors heighten an individual's chances of becoming infected if exposed to an STD, but the risk of infection is primarily affected by personal behavior: Some behaviors increase the likelihood of exposure to sexually transmitted infections, while others reduce the risk of infection if exposure does occur. Obviously, individuals who practice sexual abstinence are not at risk of infection (unless they have acquired an infection through past sexual activity). In addition, people who are in long-standing mutually monogamous relationships are not at risk, assuming neither carries an infection. (*)
* Multiple Partners. On the other hand, individuals who have multiple sexual partners--both over a given period in their life and over the course of their lifetime--have an increased risk of encountering a person who is infected with an STD; their risk rises as the number of partners increases. (+) Most Americans have more than one sexual partner over the course of their lives: On average, adults have seven lifetime partners. (41) Among women aged 15-44 who have ever had sexual intercourse, two-thirds have had more than one partner; most of these women have had at least four partners. (29) In addition to direct exposure to multiple partners, people can be exposed to multiple partners indirectly, by having sex with a person who has several sexual contacts. (29)
About six million women aged 15-44 have more than one partner each year. Another 6-11 million who have only one partner themselves maybe at increased risk of contracting an STD because their partner had multiple contacts in the last 12 months. The number of men who have had direct or indirect contact with more than one partner in the past year is as high or higher. (29)
* Condom Use. While having multiple sexual partners affects an individual's risk of exposure, use or nonuse of condoms and other barrier methods of contraception can significantly affect a person's chances of becoming infected. Latex condoms can markedly reduce the likelihood of transmission of all STDs. (++ 30) Condoms used with spermicide may be even more effective in preventing bacterial STD transmission than condoms alone. Other combination barrier-spermicide methods and spermicide used alone (ss) also provide some protection against bacterial STDs. (31,37)
Despite the clear benefits of using condoms, the vast majority of individuals with multiple partners apparently do not use them. In one study, only 17% of heterosexual men and women with multiple partners, and only 13% of those with a risky sex partner, (**) said they used condoms all the time. Some 38% of those with multiple partners and 70% of those with a risky partner said they never used condoms. (20)
In another study, only 20% of sexually active women reported using condoms; women with multiple partners were no more likely than those with one partner to use condoms. Among those who did use condoms, women with multiple partners had significantly more difficulty doing so consistently. 
* Other Factors. Some drug users, especially users of crack cocaine, support their addiction by trading sex for drugs, [6,13] a practice that often results in sexual contact with a large number of partners. This is particularly true for adolescent women who are dependent on drugs.  Prostitution and sex with prostitutes also increase an individual's direct or indirect sexual contacts. These behaviors increase the risk of exposure to an STD. Drug abuse, as well as alcohol abuse can also increase the risk of infection by affecting an individual's motivation to use condoms.
(*.) There can, however, be "risks" in the assumption of mutual monogamy. An individual is dependent on a partner's truthful report about his or her sexual behavior, since there is no way to know for certain that the partner is monogamous.
(+.) The number of an individual's recent and lifetime partners can be important in distinguishing between types of risk. Bacterial infections, such as syphilis, gonorrhea and trichomoniasis, which can be cured, are mere closely associated with the recent number of partners; viral STDs, such as HIV, HPV and herpes, which can be treated but cannot be cured, are related mere to the lifetime number of partners (29)
(++.) In addition to the male condom, a new polyurethane female condom, which also may offer protection against STDs, is under review by the Food and Drug Administration. (42)
(ss.) Questions have emerged, however, as to whether very frequent use of spermicide containing nonoxynol 9 may increase women's risk of contracting HIV. (43,44)
(**.) Defined as individuals whose primary sexual partner in the last 12 months had one or more of the following risk factors: was HIV-positive, used intravenous drugs within the last five years, was not monogamous, was a transfusion recipient or was a hemophiliac.
(1.) A.M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880, Oxford University Press, New York, 1987.
(2.) Centers for Disease Control and Prevention (CDC), "Summary of Notifiable Diseases, United States, 1990," Morbidity and Mortality Weekly Report, 39:55-60,1991.
(3.) Division of STD/HIV Prevention, Division of STD/HIV Prevention, 1992 Annual Report, CDC, Atlanta, 1993 (forthcoming).
(4.) Calculated by the Alan Guttmacher Institute (AGI) on the basis of CDC incidence data and estimates.
(5.) Division of STD/HIV Prevention, "Preventive Health Services-Sexually Transmitted Disease Accelerated Prevention Campaigns Cooperative Agreements," Announcement No.301, FY 1993, CDC, Atlanta, 1992 (draft).
(6.) S.O. Aral and K.K. Holmes, "Sexually Transmitted Diseases in the AIDS Era," Scientific American, 264:62-69,1991.
(7.) Division of STD/HIV Prevention, Sexually Transmitted Disease Surveillance 1991, CDC, Atlanta, 1992.
(8.) Division of STD/HIV Prevention, HIV/AIDS Surveillance, year-end edition, CDC, Atlanta, Feb. 1993.
(9.) Senate Committee on Appropriations, "Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriation Bill, 1993," report accompanying H.R. 5677, Report No. 102-397, Washington DC, Sept. 10,1992.
(10.) F.A. Althaus, "An Ounce of Protection...STD and Women's Health," Family Planning Perspectives, 23:173-177,1991.
(11.) Division of STD/HIV Prevention, "An Update on Sexually Transmitted Diseases (STDs)," Factsheet, CDC, Atlanta, 1992.
(12.) National Institute of Allergy and Infectious Disease (NIAID), "Hepatitis," Factsheet, NIH, Bethesda, MD, 1992.
(13.) Division of STD/HIV Prevention, Division of STD/HIV Prevention 1991 Annual Report, CDC, Atlanta, 1992.
(14.) NIAID, "Human Papillomavirus and Genital Warts," Factsheet, National Institutes of Health (NIH), Bethesda, MD, 1992.
(15.) NIAID, "Genital Herpes," Factsheet, NIH, Bethesda, MD, 1992.
(16.) J.N. Wasserheit, "Epidemiological Synergy: Interrelationships Between Human Immunodeficiency Virus Infection and Other Sexually Transmitted Diseases," Sexually Transmitted Diseases, 19:61-77,1992.
(17.) A.E. Washington and P Katz, "Cost of and Payment Source for Pelvic Inflammatory Disease: Trends and Projections, 1983 Through 2000," Journal of the American Medical Association, 266:2565-2569,1991.
(18.) Calculated by the AGI on the basis of A.E. Washington, R.E. Johnson and L.L. Sanders, "Chlamydia Trachomatis Infections in the United States: What Are They Costing Us?" Journal of the American Medical Association, 257:2070-2072,1987.
(19.) Calculated by the AGI on the basis of Institute of Medicine, New Vaccine Development: Establishing Priorities, Vol. 1, Diseases of importance in the United States, National Academy Press, Washington, DC, 1985.
(20.) S.O. Aral and M.E. Guinan, "Women and Sexually Transmitted Diseases," in K.K. Holmes et al., eds., Sexually Transmitted Diseases, McGraw-Hill, New York, 1984, pp. 85-89.
(21.) NIAID, "Pelvic Inflammatory Disease," Factsheet, NIH, Bethesda, MD, 1992.
(22.) H.H. Neumann and S. Simmons ,Dr. Neumann's Guide to New Sexually Transmitted Diseases, Acropolis Books, Washington, DC, 1987.
(23.) S.B. Toal, ed., "Sexually Transmitted Disease Strategies: Review of an Ad Hoc Panel," CDC, Atlanta, 1991 (report on a panel convened by the National Center for Prevention Services, March 18-19, 1991).
(24.) NIAID, "An Introduction to Sexually Transmitted Diseases," Factsheet, NIH, Bethesda, MD, 1992.
(25.) E.F. Jones et al., Teenage Pregnancy in Industrialized Countries, Yale University Press, New Haven, 1986.
(26.) J.D. Forrest and S. Singh, "The Sexual and Reproductive Behavior of American Women, 1982-1988," Family Planning Perspectives, 22:206-214, 1990.
(27.) National Center for Health Statistics, "Advance Report of Final Marriage Statistics, 1988," Monthly Vital Statistics Report, Aug. 26,1991 (supplement).
(28.) National Center for Health Statistics, "Advance Report of Final Divorce Statistics, 1988," Monthly Vital Statistics Report, May 21, 1991 (supplement 2).
(29.) K. Kost and J.D. Forrest, "American Women's Sexual Behavior and Exposure to Risk of Sexually Transmitted Diseases," Family Planning Perspectives, 24:244-254,1992.
(30.) J.A. Catania et al., "Prevalence of AIDS-Related Risk Factors and Condom Use in the United States," Science, 258:1101-1106,1992.
(31.) W. Cates, Jr., and K.M. Stone, "Family Planning, Sexually Transmitted Diseases and Contraceptive Choice: A Literature Update--Part I," Family Planning Perspectives, 24:75-84,1992.
(32.) M.L. Swinker et al., "Prevalence of Chlamydia Trachomatis Cervical Infection in a College Gynecology Clinic: Relationship to Other Infections and Clinical Features," Sexually Transmitted Diseases, 15:133-136,1988.
(33.) H.R. Harrison et al., "Cervical Chlamydia Tra,chomatis Infection in University Women: Relationship to History, Contraception, Ectopy, and Cervicitis," American Journal of Obstetrics and Gynecology, 153:244-251,1985.
(34.) N.B. Kiviat et al., "Prevalence of Genital Papillomavirus Infection Among Women Attending a College Student Health Clinic or a Sexually Transmitted Disease Clinic," Journal of infectious Diseases, 159:293-302,1989.
(35.) H.M. Bauer et al., "Genital Human Papillomavirus Infection in Female University Students as Determined by a PCR-Based Method," Journal of the American Medical Association, 265:472-477,1991.
(36.) A.M. Hardy, "AIDS Knowledge and Attitudes for January-March 1991: Provisional Data from the National Health Interview Study," Advance Data from Vital and Health Statistics, No.216,1992.
(37.) S. Harlap, K. Kost and J.D. Forrest, Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States, AGI, New York, 1991.
(38.) M. Shafer and R.L. Sweet, "Pelvic Inflammatory Disease in Adolescent Females," Adolescent Medicine: State of the Art Reviews, 1:545-564,1990.
(39.) D.R. Ostergard, "The Effect of Age, Gravidity, and Parity on the Location of the Cervical Squamocolumnar Junction as Determined by Colposcopy," American Journal of Obstetrics and Gynecology, 129:59-60,1977.
(40.) A. Moscicki et al., "Differences in Biologic Maturation, Sexual Behavior, and Sexually Transmitted Disease Between Adolescents With and Without Cervical Intraepithelial Neoplasia," Journal of Pediatrics, 115:487-493,1989.
(41.) T.W. Smith, "Adult Sexual Behavior in 1989: Number of Partners, Frequency of Intercourse and Risk of AIDS," Family Planning Perspectives, 23:102-107, 1991.
(42.) "FDA Panel Recommends Female Condom Approval; Efficacy Concerns Remain," Washington Memo, Dec. 21, 1992 (WM-20), pp. 1-2.
(43.) M.J. Rosenberg and E.L. Gollub, "Commentary: Methods Women Can Use That May Prevent Sexually Transmitted Disease, Including HIV," American Journal of Public Health, 82:1473-1478,1992.
(44.) W. Cates, Jr., F.H. Stewart and J. Trussell, "Commentary: The Quest for Women's Prophylactic Methods--Hopes vs. Science," American Journal of Public Health, 82:1479-1481,1992.
(45.) P. Effler et al., "High Prevalence of Chlamydia in Female Adolescents Reporting Only One Lifetime Sex Partner," paper presented at the 32nd Inter-science Conference on Antimicrobial Agents and Chemotherapy, Anaheim, CA, Oct. 11-14,1992.
(46.) W.D. Mosher and S.O. Aral, "Testing for Sexually Transmitted Diseases Among Women of Reproductive Age: United States, 1988," Family Planning Perspectives, 23:216-221, 1991.
(47.) K. Toomey, CDC, personal communication, Oct. 14,1992.
(48.) R.T. Rolfs, E.I. Galaid and A.A. Zaidi, "Pelvic Inflammatory Disease: Trends in Hospitalization and Office Visits, 1979 Through 1988," American Journol of Obstetrics and Gynecology, 166:983-990,1992.
(49.) Public Health Service (PHS), "Curbing the Increase in Rates of STDs," Prevention Report, Nov. 1991.
(50.) S.O. Aral, W.D. Masher and W Gates, Jr., "Self-Reported Pelvic Inflammatory Disease in the United States, 1988," Journal of the American Medical Association, 266:2570-2573, 1991.
(51.) J.M. Graham and J.D. Blanco, "Chlamydial Infections," Primary Care, 17:85-93, 1990.
(52.) J. Schachter, "Why We Need a Program for the Control of Chlamydia Trachomatis," editorial, New England Journal of Medicine, 320:802-804, 1989.
(53.) L.T. Gutman and G.M. Wilfert, "Gonococcal Diseases in Infants and Children," in K.K. Holmes et al., eds., Sexually Transmitted Diseases, 2nd edition, McGraw-Hill, New York, 1990.
(54.) S. Blanche et al., "A Prospective Study of Infants Born to Women Seropositive for Human Immunodeficiency Virus Type 1," New England Journal of Medicine, 320:1643-1648, 1989.
(55.) NIAID, "Syphilis," Factsheet, NIH, Bethesda, MD, 1992.
(56.) NIAID, "Other Important STDs," Factsheet, NIH, Bethesda, MD, 1992.
(57.) Bureau of the Census, "United States Population Estimates, by Age, Sex, Race, and Hispanic Origin, 1980-1988," Current Population Reports, P25-1045, 1990.
(58.) Calculated by the AGI on the basis of references 26,37 and 57 and on F.L. Sonenstein, J.H. Pleck and L.C. Ku, "Sexual Activity, Condom Use and AIDS Awareness Among Adolescent Males," Family Planning Perspectives, 21:152-158, 1989.
(59.) A.G. Randolph and A.E. Washington, "Screening for Chlamydia Trachomatis in Adolescent Males: A Cost-Based Decision Analysis," American Journal of Public Health, 80:545-550, 1990.
(60.) J.D. Forrest, AGI, personal communication, Nov.11, 1992.
(61.) A. Moscicki et al., "Human Papillomavirus Infection in Sexually Active Adolescent Females: Prevalence and Risk Factors," Pediatric Research, 28:507- 513, 1990.
(62.) A.E. Washington, R.E. Johnson and L.L. Sanders, "Chlamydia Trachomatis Infections in the United States: What Are They Costing Us?" Journal of the American Medical Association, 257:2070-2072, 1987.
(63.) A.A. Scitovsky and D.P. Rice, "Estimates of the Direct and Indirect Costa of Acquired Immunodeficiency Syndrome in the United States, 1985, 1986 and 1991,' Public Health Reports, 102:5-12, 1987.
(64.) Institute of Medicine, The Future of Public Health, National Academy Press, Washington, DC, 1988.
(65.) J. Kosterlitz, "AIDS Wars," National Journal, July 25, 1992, pp. 1727-1732.
(66.) Ryan White Comprehensive AIDS Resources Emergency Act of 1990 (Title XXVI, Public Health Service Act).
(67.) W. Cates, Jr., and K.M. Stone, "Family Planning, Sexually Transmitted Diseases and Contraceptive Choice: A Literature Update--Part II," Family Planning Perspectives, 24:122-128, 1992.
(68.) 42 U.S.C. 247c (Section 318, Public Health Service Act).
(69.) K. Toomey, GDC, personal communication, Dec. 9, 1992.
(70.) W Gates, Jr., GDC, personal communication, Dec. 8, 1992.
(71.) CDC, HIV/AIDS Prevention Fact Book 1992, Atlanta, 1992.
(72.) K. Toomey, CDC, personal communication, Sept. 25, 1992.
(73.) R. Merriweather, North Carolina Health Department, personal communication, Dec. 1,1992.
(74.) Calculated by the AGI on the basis of GDC funding data.
(75.) Division of STD/HIV Prevention, "Program Announcement and Notice of Availability of Funds for Fiscal Year 1990, Project Grants for Preventive Health Services, Sexually Transmitted Diseases Prevention," Announcement 004, GDC, Atlanta.
(76.) Public Health Foundation, Washington, DC, unpublished data, Oct. 1992.
(77.) Public Health Foundation, Public Health Agencies 1991: An Inventory of Programs and Block Grant Expenditures, Washington, DC, 1991.
(78.) P. Donovan, "Family Planning Clinics: Facing Higher Costs and Sicker Patients," Family Planning Perspectives, 23:198-203, 1991.
(79.) R.B. Gold and D. Daley, "Public Funding of Contraceptive, Sterilization and Abortion Services, Fiscal Year 1990," Family Planning Perspectives, 23:204-211, 1991.
(80.) CDC, Directory of STD Clinics, Atlanta, 1987.
(81.) K. Toomey, GDC, personal communication, Jan. 15, 1992.
(82.) S. DeLisle, James Bowman Associates, Seattle, personal communication, Dec. 7,1992.
(83.) K. Toomey, CDC, personal communication, Dec. 4, 1992.
(84.) Calculated by the AGI on the basis of data from the 1988 National Survey of Family Growth.
(85.) B. Johnson and D. Moser, CDC, personal communication, Mar. 3, 1992.
(86.) "Program Spotlight: Widespread Screening Seeks to Lower Chlamydia Prevalence," Family Planning Perspectives, 24:135-136, 1992.
(87.) Region X Chlamydia Project, "A Cost Effective Screening Program for Women in Family Planning Clinics," Factsheet, undated.
(88.) TL. Chorbaetal., "Mandatory Reporting of Infectious Diseases by Clinicians," Journal of the American Medical Association, 262:3018-3026, 1989.
(89.) N. Gibbs, GDC, personal communication, Oct. 7, 1992.
(90.) K. Toomey, GDC, personal communication, Oct. 1, 1992.
(91.) K. Toomey, CDC, personal communication, Nov. 22, 1991.
(92.) W. Cates, Jr., GDC, personal communication, Nov. 24, 1992.
(93.) J. Wasserheit, CDC, remarks made at meeting of STD Coalition, Feb. 11, 1993, Washington, DC.
(94.) H. Hunter Handsfield, "Control of Sexually Transmitted Chlamydial Infections," editorial, Journal of the American Medical Association, 257:2073-2074, 1987.
(95.) A Caughran, American Social Health Association, personal communication, Nov. 9, 1992.
(96.) "Special Report... U.S. Government Criticized for Censorship, Prudishness on Sexuality-Related Issues," Washington Memo, May 5, 1992 (WM-8), pp. 4-5.
(97.) "Preventive Health Amendments of 1992," Conference report accompanying H.R. 3635, Report No. 102-1019, Washington DC, Oct. 5, 1992.
(98.) PHS, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, U.S. Government Printing Office, Washington, DC, 1990.
(99.) A.I. Trachtenberg, A.E. Washington and S. Halldorson, "A Cost-Based Decision Analysis for Chlamydia Screening in California Family Planning Clinics," Obstetrics and Gynecology, 71:101-108, 1988.
(100.) B.G. Gellin and D.E. Rogers, "The Stalled Response to AIDS," Issues in Science and Technology, Fall 1992, pp. 24-28.
(101.) J. Rovner, "Vote to End Fetal Tissue Ban Hinged on Personal Stakes," Congressional Quarterly, Apr. 4, 1992, pp. 879-880.
(102.) AGI, Risk and Responsibility: Teaching Sex Education in America's Schools Today, New York, 1989.
Figure 5 Gender Discrimination: Women are twice as likely as men to acquire certain STDs during a single act of unprotected intercourse with an infected partner. Women Infected Men Infected by Men by Women Gonorrhea 50 25 Chlamydia 40 20 Chancroid 30 15 Hepatitis B 10 5 Source: S. Harlap, K. Kost and J.D. Forrest, Preventing Pregnancy, Protecting Health, A New Look at Birth Control Choices in the United States, AGI, New York, 1991.
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|Title Annotation:||sexually transmitted disease|
|Publication:||Testing Positive: Sexually Transmitted Disease and the Public Health Response|
|Article Type:||Topic Overview|
|Date:||Jan 1, 1993|
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