Abstracts

INTRODUCTION

Violence is a worldwide phenomenon of complex management that demands intersectoral actions. It is one of the main public health problems.^aa Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: World Health Organization; 2002. Its incidence has increased in recent years, with an impact on morbidity and mortality of the population and increasing costs to social, economic, and health care systems.¹⁰10 Miranda MPM, Paula CS, Bordin IA. Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família.Rev Panam Salud Publica. 2010;27(4):300-8. DOI:10.1590/S1020-49892010000400009^,1616 Rodrigues RI, Cerqueira DRC, Lobão WJA, Carvalho AXY. Os custos da violência para o sistema público de saúde no Brasil: informações disponíveis e possibilidades de estimação. Cad Saude Publica.2009;25(1):29-36. DOI:10.1590/S0102-311X2009000100003

Intimate partner violence (IPV) is a pattern that is difficult to break because it involves affection and economic dependence, among other things.¹1 Barros C, Schraiber LB, França-Junior I. Associação entre violência por parceiro íntimo contra a mulher e infecção por HIV. Rev Saude Publica. 2011;45(2):365-72. DOI:10.1590/S0034-89102011005000008^,1010 Miranda MPM, Paula CS, Bordin IA. Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família.Rev Panam Salud Publica. 2010;27(4):300-8. DOI:10.1590/S1020-49892010000400009 Women are the main target of this violence. However, acts of physical violence are sometimes reciprocal between the genders.²⁴24 Whitaker DJ, Haileyesus T, Swahn M, Saltzman, LS. Differences in frequency of violence and reported injury between relationships with reciprocal and nonreciprocal intimate partner violence. Am J Public Health. 2007;97:941-7. DOI:10.2105/AJPH.2005.079020. In Sao Paulo, Schraiber et al¹⁹19 Schraiber LB, Barros CRS, Castilho EA. Violência contra as mulheres por parceiros íntimos: usos de serviços de saúde. Rev Bras Epidemiol. 2010;13(2):237-45. DOI:10.1590/S1415-790X2010000200006 found a prevalence of 59.0% of IPV, and women who had experienced IPV multiple times were more likely to seek health care services.¹⁹19 Schraiber LB, Barros CRS, Castilho EA. Violência contra as mulheres por parceiros íntimos: usos de serviços de saúde. Rev Bras Epidemiol. 2010;13(2):237-45. DOI:10.1590/S1415-790X2010000200006

Previous studies have shown an association between having suffered IPV and the increased vulnerability to sexually transmitted diseases (STD).¹1 Barros C, Schraiber LB, França-Junior I. Associação entre violência por parceiro íntimo contra a mulher e infecção por HIV. Rev Saude Publica. 2011;45(2):365-72. DOI:10.1590/S0034-89102011005000008^,1111 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 Transm Dis. 2011;38(6):510-15. DOI:10.1097/OLQ.0b013e318207f59b^,1717 Schraiber LB, D’Oliveira AFPL, França Jr I. Grupo de Estudos em População, Sexualidade e Aids. Violência sexual por parceiro íntimo entre homens e mulheres no Brasil urbano, 2005. Rev Saude Publica.2008;42(1):127-37. DOI:10.1590/S0034-89102008000800015 However, only a few studies have analyzed IPV after the disclosure of the diagnosis of STD to the partner. A study conducted with adolescents attended to at reproductive health clinics in Boston, United States, observed a prevalence of 32.0% and 21.0% for physical and sexual IPV, respectively.⁹9 Miller E, Decker MR, Raj A, Reed E, Marable D, Silverman JG. Intimate partner violence and health care-seeking patterns among female users of urban adolescent clinics. Matern Child Health J.2010;14(6):910-7. DOI:10.1007/s10995-009-0520-z

Violent acts among couples where one of the partners has HIV/AIDS¹1 Barros C, Schraiber LB, França-Junior I. Associação entre violência por parceiro íntimo contra a mulher e infecção por HIV. Rev Saude Publica. 2011;45(2):365-72. DOI:10.1590/S0034-89102011005000008^,1717 Schraiber LB, D’Oliveira AFPL, França Jr I. Grupo de Estudos em População, Sexualidade e Aids. Violência sexual por parceiro íntimo entre homens e mulheres no Brasil urbano, 2005. Rev Saude Publica.2008;42(1):127-37. DOI:10.1590/S0034-89102008000800015 may compromise their physical and emotional health. It is possible that the disclosure of the diagnosis of other STD to the sexual partner leads to violence, which may account for the difficulty in treating the sexual partners of patients with STD.²2 Campos ALA, Araújo MAL, Melo SP, Gonçalves MLC. Epidemiologia da sífilis gestacional em Fortaleza, Ceará, Brasil: um agravo sem controle.Cad Saude Publica. 2010;26(9):1747-55. DOI:10.1590/S0102-311X2010000900008^,33 Decker MR, Miller E, McCauley HL, Tancredi DJ, Levenson RR, Waldman J. Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients.Int J STD AIDS. 2011;22(6):345-47. DOI:10.1258/ijsa.2011.010425

This study aimed to analyze the prevalence and factors associated with IPV after the diagnosis of STD.

METHODS

This cross-sectional study was conducted in Fortaleza, CE, Northeastern Brazil, in 2012. At present, the city has a network of health care services with three reference hospitals for treatment of individuals with STD. In 2011, 8,966 individuals diagnosed with STD visited these units.

Participants were men and women with syndromic and/or etiological diagnosis of STD. The sample size was calculated based on the population of 8,966 individuals attended to in 2011, the expected frequency of IPV of 18.0% among patients treated at STD clinics,¹¹11 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 Transm Dis. 2011;38(6):510-15. DOI:10.1097/OLQ.0b013e318207f59b a sampling error of 5%, and a 95% confidence interval (CI), and totaling to 221 individuals.

The study included individuals diagnosed with STD who were monitored at one of the clinics, who had had at least two consultations, who had a maximum diagnosis time of three months, and who had disclosed the diagnosis to their sexual partner. In Brazil, it is a routine practice for health care services to instruct STD patients to return to the clinic for treatment assessment.^bb Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e Aids. Manual de controle das doenças sexualmente transmissíveis. 4a ed. Brasília (DF): Ministério da Saúde; 2006. The criterion “individuals who attended at least two consultations” was included to ensure that there would be enough time to disclose the diagnosis to the sexual partner.

Individuals diagnosed with HIV/AIDS, those who had mental illnesses, and those who had no sexual partner at the time of diagnosis were excluded. STD must be identified and treated in primary health care units; the control efforts are neglected when compared with those for HIV/AIDS.¹⁴14 Ramos Jr AN, Matida LH, Saraceni V, Veras MASM, Pontes RJS. Control of mother-to-child transmission of infectious diseases in Brazil: progress in HIV/AIDS and failure in congenital syphilis. Cad Saude Publica.2007;23(Suppl 3):370-8. DOI:10.1590/S0102-311X2007001500005 Measures to prevent the transmission of HIV/AIDS are widely disseminated, funded, and implemented and are independently assessed from those focused on other STD.

IPV is defined as any intentional act in an intimate relationship that causes physical, psychological, or sexual harm to individuals in that relationship; i.e., physical and psychological violence, rape, and other forms of sexual coercion, in addition to various dominant behaviors, such as isolating a person from their family or friends, watching their movements, or restricting their right to information or health care. Intimate partners included sexual partners, husband/wife, boyfriend/girlfriend, fiancé(e), or any other individual with whom an intimate-affective relationship was established.

Data were collected between March and September 2012 using a questionnaire applied during an interview conducted in a private room. All patients in the waiting room of the STD outpatient clinics were asked whether they were there for a follow-up visit; those who responded positively and met the inclusion criteria were invited to participate in the study.

The questionnaires were administered by an appropriately trained nurse experienced in approaching STD patients and skilled in managing issues related to the theme of violence. It was considered that the gender of the interviewer did not affect the quality of data collected from male participants.

The questionnaire comprised the following variables: sociodemographic variables (gender, age, education, and personal and family income); behavioral variables (number of sexual partners, sexual orientation, extramarital relations, consumption of alcohol, use of illicit drugs, and use of condoms); institutional and clinical variables (type of STD and approach taken by the health care service with respect to violence); and variables regarding violence suffered before and after the diagnosis of STD (nature of violence, frequency). The dependent variable was IPV after the disclosure of the diagnosis of STD to the sexual partner.

IPV was categorized as psychological, physical, or sexual and was considered present when the respondent answered affirmatively to at least one of the questions regarding violence.

The questions related to IPV were elaborated using, as reference, the questionnaire from the international study on women’s health and domestic violence from the World Health Organization validated in Brazil.¹⁸18 Schraiber LB, Latorre MRD, França Jr I, Segri NJ, D’Oliveira AFPL. Validade do instrumento WHO VAW STUDY para estimar violência de gênero contra a mulher. Rev Saude Publica. 2010;44(4):658-66. DOI:10.1590/S0034-89102010000400009^,aa Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World report on violence and health. Geneva: World Health Organization; 2002.

A total of 234 individuals were considered eligible, of who 5.5% refused to participate. Of the 221 individuals with STD included in the present study, 40.3% were men and 132 (59.7%) were women. Most patients (68.3%) were treated for genital wart, 18.6% for syphilis, 8.1% for genital herpes, 3.2%, for gonorrhea, 0.9% for trichomoniasis, and 0.5% for pelvic inflammatory disease and donovanosis.

Table 1 presents the demographic data of the participants. The mean age was 30.3 years (52.5% were younger than 29 years), 59.7% individuals had more than nine years of education, and 80.5% reported non-white ethnicity. In addition, 69.2% of the individuals were married or living in common law marriage. The average monthly personal income was R$540.69, and the majority (63.8%) earned up to one Brazilian minimum wage.

Descriptive analysis was performed using the distribution of frequencies for categorical variables and the mean and standard deviation for numerical variables. In the bivariate analysis, Pearson’s Chi-square test and Fisher’s exact test were used to determine statistical associations between categorical variables, establishing a 5% significance level and a 95%CI. Data were entered and stored into the Statistical Package for the Social Sciences, version 19.0.

Multivariate analysis was performed using a logistic regression model and the stepwise technique. For the adjusted analysis, only the variables with a p-value < 0.05 were included. The odds ratio (OR) with a 95%CI was used as a measure of effect. The Stata statistical package version 11.0 was used for the statistical analysis.

This study was approved by the Research Ethics Committee of the Universidade de Fortaleza (Protocol 437/2011) and the Hospital Universitário Walter Cantídio (Opinion 043.06.12) and met the WHO recommendations for research on domestic violence.^cc Word Health Organization. Putting Woman First: Ethical and Safety Recommendations for Research on Domestic Violence Against Women. Geneva; 2001. All participants signed an informed consent form. Considering that these individuals were receiving treatment for STD, a situation in which the HIV test is offered, and that adolescents have autonomy for decision-making in such circumstances,^dd Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e AIDS. Implicações Éticas do Diagnóstico e da Triagem Sorológica do HIV. Brasília (DF); 2004. the need for an informed consent form signed by the parents of individuals under 18 years was waived.

RESULTS

Of the individuals included in the present study, 30.3% reported having experienced some form of violence after the diagnosis of STD (28.8% women and 32.6% men, without statistical significance). Moreover, 27.6% of the individuals reported experiencing psychological violence; 5.9%, physical; and 7.2%, sexual. Only one subject (0.5%) reported having denounced the partner’s violence to the police; 5.4% of the respondents indicated that the subject of violence was addressed by health care professionals during treatment (data not shown).

IPV was associated with having more than one sexual partner in the last three months (p = 0.001), extramarital relations (p = 0.000), history of violence prior to diagnosis (p = 0.011), fear of disclosing the diagnosis to the partner (p = 0.008), extramarital relations by the partner (p = 0.001), and alcohol consumption by the partner (p = 0.026; Table 2).

Table 3 presents the analysis of individuals diagnosed with STD who had experienced IPV, stratified by gender, and the behavioral variables of the sexual partner. The variables extramarital relations by the partner (p = 0.001) and alcohol consumption by the partner (p = 0.001) presented statistical significance for men and women who suffered IPV.

The variables that remained statistically significant for IPV after the disclosure of the STD diagnosis, considering the raw and adjusted analyses, were as follows: STD carrier having had extramarital relations (OR = 3.72; 95%CI 1.91;7.26; p = 0.001), history of violence prior to the STD diagnosis (OR = 2.87; 95%CI 1.44;5.69; p = 0.003), fear of disclosing the diagnosis to the partner (OR = 2.66; 95%CI 1.32;5.32; p = 0.006), and partner’s consumption of alcohol (OR = 2.16; 95%CI 1.08;4.33; p = 0.026) (Table 4).

DISCUSSION

The prevalence of IPV after the disclosure of the diagnosis of STD was 30.3%. Only one individual reported the violence to the police. Among those who suffered physical violence, three believed that they needed medical care but none sought health care services. IPV victims claimed to experience shame for exposing their problems and fear of the partner’s reaction as the main reasons for not seeking health care services.¹⁰10 Miranda MPM, Paula CS, Bordin IA. Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família.Rev Panam Salud Publica. 2010;27(4):300-8. DOI:10.1590/S1020-49892010000400009

It has been observed that the disclosure of the STD diagnosis triggers violence in relationships, a condition that should be considered during counseling, especially considering the need to medically assess the sexual partners. Fear of the partner’s reaction is one of the main reasons related to the difficulty in treating the sexual partners of individuals with STD. A survey of women at family planning clinics demonstrated that the partners of women who suffered IPV were less frequently screened and treated for STD.³3 Decker MR, Miller E, McCauley HL, Tancredi DJ, Levenson RR, Waldman J. Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients.Int J STD AIDS. 2011;22(6):345-47. DOI:10.1258/ijsa.2011.010425

Gender issues may be related to the problem of STD transmission and can interfere in the treatment of sexual partners. A study conducted on men in Bangladesh demonstrated that 36.8% reported practicing physical and/or sexual violence to their wives; those who practiced violence had more extramarital relations and STD symptoms.²⁰20 Silverman JG, Decker, MR, Kapur NA, Gupta J, Raj A. Violence against wives, sexual risk and sexually transmitted infection among Bangladeshi men.Sex Transm Infect. 2007;83(3):211-5. DOI:10.1136/sti.2006.023366 The possibility of extramarital affairs as one of the reasons for the emergence of STD can be a major cause of IPV, considering that the probability of suffering IPV was three times higher when the respondent had extramarital affairs.

In the present study, 68.3% of the respondents had human papilloma virus (HPV) infection, which was predominant among women (60.3%). This incidence was higher than the overall rate of 41.2% in HPV infection among people seeking STD services in Brazil.^ee Ministério da Saúde. Secretaria de Vigilância em Saúde. Programa Nacional de DST e AIDS. Prevalências e frequências relativas de Doenças Sexualmente Transmissíveis (DST) em populações selecionadas de seis capitais brasileiras, 2005. Brasília (DF); 2008. Health care professionals should explain to the patient that some infections have a long incubation period and that this situation can minimize IPV. There is a possibility that the infection was contracted in a previous relationship, which could mitigate the conflicts generated by disclosure of the diagnosis to the partner.

The likelihood of suffering IPV after the disclosure of diagnosis was 2-fold higher (OR = 2.17) when the partner was an alcohol consumer. Alcohol reduces self-control and affects cognitive and physical functioning,¹⁵15 Ray LA, Mackillop J, Leventhal A, Hutchison KE Catching the alcohol buzz: an examination of the latent factor structure of subjective intoxication.Alcohol Clin Exp Res. 2009;33(12):2154-61. DOI:10.1111/j.1530-0277.2009.01053.x which may compromise an individual’s ability to resolve relationship conflicts without resorting to violence. Alcohol consumption increases the occurrence and severity of domestic violence⁵5 Fonseca AM, Fernandes Galduróz JC, Tondowski CS, Noto AR. Padrões de violência domiciliar associada ao uso de álcool no Brasil. Rev Saude Publica. 2009;43(5):743-9. DOI:10.1590/S0034-89102009005000049 and is a strong determinant of IPV.²²22 Tumwesigye NM, Kyomuhendo, GB, Greenfield TK, Wanyenze RK. Problem drinking and physical intimate partner violence against women: evidence from a national survey in Uganda. BMC Public Health. 2012;12:399. DOI:10.1186/1471-2458-12-399

In this study, the incidence of sexual violence was higher than physical violence. In private, IPV may occur more subtly, in the form of psychological and/or sexual violence, and it may not be identified by the victim as a kind of violence. When associated with the diagnosis of STD, the situation tends to worsen because it limits the use of condoms.⁸8 Lary H, Maman S, Katebalila M, Mbwambo J. Exploring the association between HIV and violence: young people’s experiences with infidelity, violence and forced sex in Dar es Salaam, Tanzania. Int Fam Plan Perspect. 2004;30(4):200-6. DOI:10.1363/3020004^,2121 Silverman JG, McCauley HL, Decker MR, Miller E, Reed E, Raj A. Coercive Forms of Sexual Risk and Associated Violence Perpetrated by Male Partners of Female Adolescents. Perspect Sex Reprod Health.2011;43(1):60-65. DOI:10.1363/4306011 Women attend health care services more often and have more opportunities to be diagnosed with STD. Men traditionally avoid seeking health care services that do not have appropriate receptiveness.⁷7 Gomes R, Moreira MCN, Nascimento EF, Rebello LEFS, Couto MT, Schraiber LB. Os homens não vêm! Ausência e/ou invisibilidade masculina na atenção primária. Cienc Saude Coletiva. 2012;16 Suppl1:983-92. DOI:10.1590/S1413-81232011000700030 Services dedicated to male health have only recently been implemented.^ff Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Política nacional de atenção integral à saúde do homem: princípios e diretrizes. Brasília (DF): Ministério da Saúde; 2009. Women coping with recurrent IPV present a higher frequency of the use of health care services and health-related complications; this greater use of health care services is related to the severity and repetition of the acts of violence.¹⁹19 Schraiber LB, Barros CRS, Castilho EA. Violência contra as mulheres por parceiros íntimos: usos de serviços de saúde. Rev Bras Epidemiol. 2010;13(2):237-45. DOI:10.1590/S1415-790X2010000200006 It is important that health care professionals assess whether users of reference health care services for STD are experiencing violence. Individuals already living in a situation of violence prior to the diagnosis are twice as likely to suffer violence after the diagnosis of STD. Accordingly, a study conducted in New York, United States, with economically disadvantaged women demonstrated that those who had experienced IPV once in their lifetime were at a risk of experiencing repeated violence.¹²12 O’Donnell L, Agronick G, Duran R, Myint-U A, Stueve A. Intimate partner violence among economically disadvantaged young adult women: associations with adolescent risk-taking and pregnancy experiences.Perspect Sex Reprod Health. 2009;41(2):84-91. DOI:10.1363/4108409

In the present study, individuals who reported fear of disclosing the diagnosis of STD to their partners were twice as likely to experience IPV after the disclosure (OR = 2.66), a situation also observed in California, United States, where women who suffered IPV reported a fear of disclosing the diagnosis to their partners.³3 Decker MR, Miller E, McCauley HL, Tancredi DJ, Levenson RR, Waldman J. Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients.Int J STD AIDS. 2011;22(6):345-47. DOI:10.1258/ijsa.2011.010425

The difficulty in treating the sexual partners of individuals with STD is a reality that has low resolution by traditional treatment methods by health care services.⁶6 Golden MR, Whittington WL, Handsfield HH, Hughes JP, Stamm WE, Hogben M, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. New Engl J Med.2005;352(7):676-85. DOI:10.1056/NEJMoa041681 Establishing an effective strategy is still a challenge for health care managers and professionals. There appears to be no single effective way to minimize this problem.⁴4 Ferreira A, Young T, Mathews C, Zunga M, Low N. Strategies for partner notification for sexually transmitted infections, including HIV.Cochrane Database Syst Rev. 2013 Oct 3;10:CD002843. DOI:10.1002/14651858.CD002843.pub2 However, requesting the partner to attend a medical consultation is an extremely important measure because it provides an opportunity for clinical assessment and medical treatment, thereby limiting the spread of infection.

The low reporting of violence and low demand for medical care by victims reinforce the findings of a study conducted in women living in a city in the metropolitan region of Sao Paulo, Southeastern Brazil, which demonstrated that shame to expose the problem and fear of the partner’s reaction were the main reasons reported for not seeking help.¹⁰10 Miranda MPM, Paula CS, Bordin IA. Violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família.Rev Panam Salud Publica. 2010;27(4):300-8. DOI:10.1590/S1020-49892010000400009

This study presented important data for the health care services that attend to individuals with STD; however, there are some limitations. Some measures employed to the minimize omission of information were adopted; however, as STD and IPV are two themes that are difficult to approach and are of intimate nature, respondents may have felt discomfort and not disclosed certain information. Nonetheless, the present results are relevant and emphasize the importance of considering the problem of violence as one of the aspects that can hamper treatment of the sexual partners of STD patients.

The majority (94.1%) of the individuals at reference health care services for STD reported that the topic of violence had not been addressed by health care professionals during the consultation, indicating the lack of opportunity to deal with sensitive issues. This difficulty is partially because of the lack of contact with the subject during medical school¹³13 Pedrosa CM, Spink MJP. A violência contra mulher no cotidiano dos serviços de saúde: desafios para a formação médica. Saude Soc.2011;20(1):124-35. DOI:10.1590/S0104-12902011000100015 or even in continuing education programs, as well as the lack of awareness of violence as a public health problem.²³23 Vieira EM, Perdona GCS, Almeida AM, Nakano MAS, Santos MA, Daltoso D, et al. Conhecimento e atitude dos profissionais de saúde em relação à violência de gênero. Rev Bras Epidemiol. 2009;12(4):566-77. DOI:10.1590/S1415-790X2009000400007

The results of this study highlighted the need for intersectoral efforts and commitment of health care professionals and managers during counseling in order to identify and prevent IPV in individuals with STD.

Prevention and health care promotion guidelines should address the fears related to the disclosure of STD diagnosis to the partner, particularly among those who have experienced IPV. The potential threat of psychological, physical, and sexual violence in response to the disclosure should also be considered. All STD patients should be advised by health care services about the possibility of IPV after the disclosure of the diagnosis of STD to the sexual partner in order to minimize the possible consequences.

REFERENCES

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