Clinical:Case Study: Barriers to Wellness

History

Ms. CLH is a 27-yo single African American woman with questions about protecting herself from sexually transmitted infections (STIs). She has not been sexually active for several months, but she met a man with whom she would like to become intimate. She feels nervous about “all those diseases out there.” Her last sexual partner was a man, and on further questioning, she states that she has also been intimate with women. Her sexual practices (with both men and women) include kissing, oral intercourse, and digital and penile penetration of her vagina but not her rectum.

She has had 4-day regular, light periods since age 13. Denies any current or past genital lesions, vaginal discharge, odor, itching or rash. LMP normal one week ago.

Denies fevers, chills, sweats, and abdominal pain. No hx of intravenous drug use. Has never been diagnosed with an STI, but wants to be checked.

Ms. CLH has a Masters in Education, teaches high school, does educational consulting, and lives with her dog. Does not use tobacco, alcohol or recreational drugs.

Exam

Vital signs, and physical exam were normal, including normal breast and pelvic exams.

Studies

Pap, wet mount and GC/Chlam studies all nl. HIV test pending.

Discussion

Sexually transmitted infections are a major public health concern. Pathogens include viruses, bacteria, and protozoa. To date, behavioral change and barrier protection are the two methods proven to slow transmission of STIs. Barrier methods include:

• male condoms
• female condoms
• latex gloves
• dental dams
• spermicides
• diaphragms
• cervical caps.

The medical community has promoted male condoms (with and without spermicide) as the best method to prevent STI transmission. They prevent fluid exchange and provide a complete barrier between the penis and the various mucosal surfaces. While male condoms are an excellent method for some sexual partners, the best barrier method is based on sexual practice, not on generalizations.

Oral intercourse and digital penetration can also transmit STIs. Notably, these practices encompass woman to woman, as well as man to woman, transmission. Therefore it is important to recognize and educate Ms. CLH, and all patients, about multiple barrier methods, esp. less popular ones, e.g., dental dams and latex gloves.

Finally, the interpersonal dynamic between heterosexual partners is an important aspect of barrier choice for women. Often women feel unable to negotiate male condom use due to culturally sanctioned male dominance in relationships. Perhaps for this reason, several recent studies have shown that male condom use, while increasing, is still disappointingly low, and often inconsistent. (1) Other studies comparing couples who use male condoms to those who use female-controlled methods (i.e., diaphragms, spermicides, and cervical caps) show that STI incidence is the same or decreased with female-controlled methods. (2) This occurs despite women-controlled methods that provide incomplete coverage of mucosa and suboptimal protection from fluid exchange, and probably is due to more consistent use. With these facts in mind, it is important to discuss methods that women control.

One of the newer barrier methods is the female condom. The female condom provides a complete fluid barrier, covers the labia, vaginal mucosa, and the cervix, and fails much less often than the male condom. If used as consistently as other women-controlled devices, perhaps the female condom is the most important barrier method to recommend to our female patients.

Plan

Ms. CLH wants to be in a monogamous, heterosexual, sexually-active relationship. I stressed the importance of frank communication between partners about sexual history and practices prior to any sexual intimacy. I advised HIV testing if she or her partner had had more than three partners in the last five years, or if she or her partner had engaged in any high-risk activities, e.g., anal intercourse, use of IV drugs, intercourse with an IV drug user, or if either has had prior STIs. I recommended experimentation with male and female condoms (with and without spermicide), and use of dental dams and latex gloves. I dispensed samples of each.

We arranged a recheck in four weeks to discuss her experience and choices. I invited her to bring her partner if he wished to join our discussion, or had any particular questions or concerns.

References

1. Upchurch, D.M., et. al. Prevalence and patterns of condom use among patients attending a sexually transmitted disease clinic. Sex Trans Dis, 1992;19(3):175-80.

2. Rosenberg, M.J., et. al. Commentary: Methods that women can use that may prevent sexually transmitted disease, including HIV. Am J Pub Hlth,1992;82:1473-78.