Intimate partner violence,partner notification,and expedited partner therapy: a qualitative study

Abstract

Summary

Over one-third of women experience intimate partner violence (IPV) in their lifetime. IPV increases the risk of infection and re-infection with sexually transmitted infections (STIs). The extent to which health care providers consider IPV when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers’ views on IPV and STIs when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients’ safety and believed assessing for IPV was needed before provision of expedited partner therapy, nearly a third had not considered the links between IPV and STIs. Strategies used by health care providers to assess for IPV did not include inquiry about specific behaviours related to IPV, STI risk, and sexual coercion. Many health care providers understand the risk for IPV in the setting of STI treatment, yet a significant portion of those interviewed failed to recognise the link between IPV and STIs. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about IPV to more safely recommend expedited partner therapy.

Keywords

Intimate partner violence sexually transmitted infections treatment sexual violence partner notification expedited partner therapy

Introduction

Over one-third of women experience intimate partner violence (IPV), defined as emotional, physical, or sexual abuse by an intimate partner, in their lifetime, with the highest prevalence among women aged 15 to 24.^1,2 IPV increases the risk for sexually transmitted infections (STIs)^1,3–5 through multiple mechanisms including sexual coercion, which can involve forced condom non-use, threats of violence with condom negotiation, pressure to have sex, and intentional exposure by a partner to an STI.^3,6,7 Additionally, IPV likely contributes to increased risk for STI re-infection as a result of fear of partner notification and partner refusal to seek treatment.⁸ Research indicates that women in abusive relationships are indeed at greater danger if they disclose their STI status.⁹

Health care providers (HCPs) usually urge patients being treated for STIs to notify their sexual partners to seek treatment or with consent of the patient may contact the patient’s sexual partners themselves.¹⁰ However, research indicates that these forms of partner notification do not often result in treatment of partners.^10,11 In recent years, the Centers for Disease Control and Prevention (CDC) has sought to implement innovative ways to treat partners of individuals with chlamydia.¹² One approach to reduce re-infection with chlamydia is expedited partner therapy (EPT), a strategy that involves empirically treating sexual partners without requiring them to undergo screening or medical examination. The most commonly used form of EPT is patient-delivered partner therapy in which the patient receives a prescription or medication to treat the infection for his/her sexual partner(s). Several randomised controlled trials comparing EPT to standard partner referral have found that EPT reduces rates of re-infection significantly in addition to increasing the number of people treated for the infection.^13–15

The American College of Obstetricians and Gynecologists (ACOG) has underscored the importance of assessing for IPV prior to offering EPT to patients.¹⁶ Understanding if HCPs recognise the impact of IPV on STI risk and what strategies they use to assess their patients’ safety in the context of STI treatment is needed to guide the safe integration of EPT into routine clinical practice. In a qualitative study focused on HCPs’ use of EPT, we explored providers’ views on IPV and STIs and their perceived role in addressing IPV when recommending partner treatment to patients.

Materials and methods

A purposive sample of HCPs who treat young women at risk for chlamydia was recruited from a large health care system in Pittsburgh, PA, to take part in open-ended, in-depth interviews. Approximately 100 providers from adolescent medicine, internal medicine, family medicine, and obstetrics/gynaecology departments were emailed to participate in the study or referred by colleagues to participate in this study. Sample size was determined by content saturation and by fulfilling a sampling matrix that included a range of disciplines as well as levels of training. Providers were asked about their perspectives regarding partner notification and treatment, specifically provision of EPT, as well as their experiences and concerns regarding addressing IPV in the context of STI treatment. Providers were specifically asked about using EPT for chlamydia because current treatment regimens for gonorrhoea make EPT use impractical for that infection.¹⁷ The University of Pittsburgh institutional review board approved this study.

The primary investigator conducted all 23 interviews. The interviews took 15 to 40 min, and HCPs received $50 as compensation for their participation. Participants also completed a brief demographic survey (i.e. gender, age, years practising medicine, specialty, profession, and practice setting). Interviews were audio recorded, transcribed, and uploaded into the Atlas.ti v.6 software program. Two independent coders (ER and CP) coded the transcripts using a thematic analysis approach.¹⁸ The initial codebook was created after completion of the first five interviews, and more codes were added after reviewing additional interviews. The two coders coded all transcripts using the finalised codebook; the coders discussed any discrepancies, and no significant differences emerged. Content saturation was achieved around the key themes related to IPV and partner treatment after 15 interviews.

Results

Of the 23 HCPs who participated in the study, 91% were physicians and 9% were nurse practitioners (Table 1). Close to 35% of participating providers practised internal medicine, 30% practised obstetrics/gynaecology, 22% practised adolescent medicine, and 13% practised family medicine. Over 90% of the providers were women and the majority were between the ages of 30 and 49. Some of the providers interviewed felt that they had some knowledge about the practice of EPT, but seven providers noted that they did not know a great deal about EPT. Five respondents had never used EPT, seven had used EPT in the past but were not currently doing so, four had used EPT less than five times, and seven HCPs routinely used EPT. Several key themes emerged in the interviews; these themes are described in more detail below.

Table 1.

Demographic characteristics of study participants.

Demographics	N = 23 (%)
Age (years)
<30	3 (13)
30–39	9 (39)
40–49	8 (35)
50–59	3 (13)
Gender
Men	2 (9)
Women	21 (91)
Specialty
Adolescent medicine	5 (22)
Family medicine	3 (13)
Internal medicine/women’s health	8 (35)
Obstetrics/Gynaecology	7 (30)
Years practising (including residency)
0–5	7 (30)
6–10	3 (13)
11–20	9 (39)
21–30	4 (17)
Profession
Physician	21 (91)
Nurse practitioner	2 (9)
Practice setting (all that apply)
Hospital-based	17 (74)
Primary care	7 (30)
Community-based	2 (9)
Other	1 (4)

Lack of recognition of the role of IPV in infection with STIs

Almost one-third of the HCPs interviewed did not believe violence was a large concern for their patients or ever considered the subject. When asked if they had concerns about the potential for violence when a patient provides medication or a prescription for their partner to treat chlamydia or discloses their infection status, respondents said things such as:

If she told him and he was concerned about … infidelity or unfaithfulness I could see how that could precipitate violence of some sort. But it hasn’t, it’s embarrassing to say, it hasn’t really crossed my mind (#1, Ob/Gyn).

I don’t. And it has not really crossed my mind … So I have not had an issue where someone was afraid to tell her partner that she was infected, thinking like maybe he thought she was promiscuous (#3, Ob/Gyn).

I haven’t thought about it. I don’t, my guess is, and I have no statistics to back it up, that if a woman was already in an abusive relationship … I doubt that she would tell them (#10 Adolescent Medicine).

Some providers are not aware of how a STI disclosure could precipitate violence or increase violence for women who are already involved in violent relationships. For example, one physician expressed her concern about violence but realised she had never counselled her patients about safe ways to talk to their partners. She stated:

But I’ve never had a conversation with a patient about … tips and tricks on how to tell your partner you have chlamydia … I’ve never thought about that before. And I think it’s good that you and I are talking about that today because it’ll definitely come in to my mind the next time I am talking about this (#8, Ob/Gyn).

Concerns about IPV

Many providers are concerned about violence and did discuss this issue with their patients. One provider stated that she believed violence played a role in re-infection:

When we ask our patients, when we counsel them to have their partner treated and they say yes, yeah, we will do that I think that sometimes when they don’t, and they get reinfected, it’s not because they were careless or wanted to get chlamydia again … they either just forgot because chlamydia is asymptomatic or was not a concern for them or that there is a real threat of intimate partner violence (#5, Ob/Gyn).

Two providers asserted that their concern for violence is related to disclosure of STI infection and that provision of EPT does not change the potential for violence.

Yeah, and I mean the same concern is true for non-EPT, right? The concern really arises from discussion of this STD … That’s between these two partners and whether or not there’s an issue of violence there … The treatment piece of it is not really affected by it directly. It’s more about the raising the question of there’s now a sexually transmitted infection and where did it come from and whether or not that’s going to create violence (#21, Ob/Gyn).

Do I have fears of violence? I would say I don’t think of putting the pills in her hand as something that is more or less likely to create violence than the challenge of disclosing and having to discuss an infection, which is always a challenge in a relationship (#4, Internal Medicine).

HCPs noted the importance of addressing the threat of IPV when providing EPT, given the potential of harm to patients. Several providers noted that concerns about IPV might prevent them from using EPT as a form of STI treatment for their patients.

So certainly if there was a concern for violence then it makes EPT not really feasible … you wouldn’t want to put your patients at risk there. So that needs to be addressed before you just go telling patients to do this (#21, Ob/Gyn).

I might get a little bit of a gauge and if any of those things had flagged earlier in the encounter … then I might sort of explore that a little bit more with her … if she felt like telling her partner about her sexually transmitted infection, that it would increase her likelihood of experiencing violence, you know I might be less likely to do it (#18, Internal Medicine).

If you think about it, especially in our population, [EPT] probably is a bit of a double-edged sword, because then you are putting a lot of the, kind of the onus on the patient to be the one to treat her partner … obviously it’s kind of a sensitive topic for partners to discuss, especially when one is diagnosed with an STD. But I think that there is probably possible domestic violence issues and things like that. So I feel like you would probably have to get a good assessment of that (#2, Ob/Gyn).

One provider did assert that fears of IPV should not eclipse the need for EPT. She stated that:

With the rise of chlamydia, violence to the partner is important to take into account, but I think that we can’t lose the forest in the trees. I think we have to safeguard against violence but if it keeps us from doing expedited partner therapy … We are going to miss a lot of women and a lot of women are going to come back reinfected (#10 Adolescent Medicine).

IPV assessment by HCPs

In general, providers asked similar types of questions around IPV.

I ask like if they feel safe in their relationship, if they feel pressured or, or you know, if they felt pressure to have sex or to do something they didn’t want to do, or [were] touched inappropriately … And then I’ll kind of ask them if they give this prescription to their partner like what do they think will happen (#7, Adolescent Medicine).

For every woman that I am seeing in clinic … Well, I usually ask things like, you know, tell me about your relationship, you know do you feel safe at home? … Has there ever been a time where you felt unsafe or is [sic] there ever been a time when you felt threatened? … So I usually ask those types of questions (#18, Internal Medicine).

However, several providers, when explaining their screening process, asserted that they did not believe that they necessarily had effective means to determine the safety of their patients.

I always sort of ask what their contraceptive sexual issues are and then probably about once a year I ask them about like their relationship and you know, if they are active and do they feel safe and blah, blah, blah … they haven’t determined what’s the best way to ask that (#16, Internal Medicine).

Providers did not report asking patients directly about whether sexual coercion contributed to their infection. When HCPs asked about IPV, they used questions such as ‘do you feel safe in your relationship?’ rather than targeted questions about forced condom non-use, forced sex, or any other forms of sexual coercion.

Supports needed to address IPV

A number of participants underscored the need to train providers to assess for IPV and that supports, such as prompts and clinical guidelines, to address IPV in the context of partner notification and use of EPT, are limited.

You know, I think we need to help clinicians deal with the violence issue (#10 Adolescent Medicine).

I think that we would try, I mean I think we do try very hard to make sure that there is not intimate partner violence and that they are in a safe situation … I don’t think that we get a lot of training on [IPV] (#5, Ob/Gyn).

Some providers had more awareness and training around partner notification of STIs. For instance, adolescent medicine providers were more cognizant of IPV and discussed tools available, such as websites, to help with anonymous partner notification.

We are lucky in where I’m working we have relationships with our patients over time so generally we might have a feel for that [IPV]. But we are also trained to screen for it and we have resources to connect people, young women with, to help with that (#6, Adolescent Medicine).

I know there is a website and stuff too that you can go to, to have them log on, if they feel uncomfortable kind of telling their partner, giving their partner the prescription (#7, Adolescent Medicine).

Discussion

This is the first study to qualitatively examine HCPs’ perspectives on IPV in the context of treatment for an STI, specifically chlamydia, and use of EPT. While many providers reported concern for their patients’ safety and endorsed the need for IPV assessment before recommending partner notification and offering EPT, nearly a third of HCPs had not considered the need to assess for IPV in the context of STI treatment. Additionally, strategies to assess for IPV did not include inquiry about specific behaviours related to sexual coercion (such as forced condom non-use), which may be particularly relevant in the context of STI management.¹⁶

Given the prevalence of IPV and research that has established the strong association between IPV, including sexual coercion, and STIs, it is troubling that nearly a third of the HCPs interviewed voiced no worries or concerns about violence. In addition, when asked about the ways in which they ask about IPV, none of the providers reported conducting any targeted assessment for coercive sex, including questions about partner’s condom non-use, threats of violence with condom negotiation, pressure to have sex, and partner refusal to seek treatment. All of these forms of sexual coercion increase the risk for exposure and infection with an STI.⁷ However, many HCPs believed that IPV was a potential concern relevant to the provision of EPT, and some had concerns about giving medication or prescriptions to patients for their partners without knowing if it would be safe for their patients to do so. In fact, a few participants asserted that fears about IPV would prevent them from providing EPT to their patients if they felt their patient would potentially be in a dangerous situation.

The lack of recognition of the role of IPV in increasing women’s risk for infection highlights the need for provider education and training on how to assess patients for IPV and how to address positive disclosures. Multiple barriers for providers to address IPV in the clinical setting are well documented, including provider discomfort, lack of self-efficacy, and lack of time.¹⁹ According to the American Medical Association, ACOG and the US Preventive Services Task Force, assessing women for IPV should be done regularly and be a routine part of taking a patient’s medical history.^16,20,21 There is, however, no uniform set of questions recommended by these organisations. ACOG specifically recommends providers have resources on hand, including community resources and patient education cards on IPV, including sexual coercion, and also provides examples of targeted assessment questions to ask patients of reproductive age.¹⁶ The CDC do not include any recommendations or guidance related to IPV in their EPT guidelines.¹² Expanding their recommendations to include specific guidance on how to address IPV might be an important way to increase inquiry about the risk for violence when offering EPT.

In addition, research indicates that educating women about the impact of IPV on their health can increase self-efficacy around condom negotiation as well as connect women with IPV resources and services.^22–26 However, there are no evidence-based clinical interventions to educate patients about the link between IPV and STIs, address fears around partner notification, provide IPV-related resources, and offer safer strategies for ensuring partners receive treatment (including anonymous notification).⁷ More research is needed to provide HCPs with an effective means to address IPV in the context of partner notification and STI treatment.

There are several limitations to this study. As an exploratory study with a convenience sample of HCPs in western Pennsylvania, findings may not be generalisable to providers from other regions and lack external validity. The study relied on a self-selected pool of providers, most of whom were women, willing to take the time to discuss issues around partner notification of STIs and EPT. However, we did garner a wide range of perspectives about IPV and partner notification and EPT. One of the strengths of this study is that the providers worked in diverse clinical settings (hospital-based, community-based, and primary care) and came from multiple specialties (adolescent medicine, internal medicine, family medicine, and obstetrics/gynaecology). If we had a larger sample and had selected participants on whether they had or had not used EPT, our results may have been different. The majority of providers in our study did not regularly use EPT, future studies could assess if providers who regularly use EPT have different perspectives and IPV screening practices.

Many providers understand the risk for IPV in the setting of STI treatment. Yet, even in this small sample, a significant portion of providers interviewed failed to recognise or did not have concerns about the relationship between IPV and STIs, and most did not directly assess for coercive sex. Provider education is necessary to increase both knowledge and skills in IPV assessment to more safely implement partner notification and treatment, including EPT. Moreover, further research is essential to provide HCPs with evidence-based strategies to address IPV in the context of STI treatment. More specifically, as EPT becomes more widely accepted within the health care community in the US, clinic-based prompts and guidance for providers assessing for IPV should be integrated into EPT provision.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding from the Myrna Silverman Award and William Green Award from the University of Pittsburgh.

Disclaimer

The opinions expressed in this work are those of the authors and do not necessarily represent the policies of the funders, institutions, the US Department of Veterans Affairs, or the US government.

References

Silverman

Raj

Clements

. Dating violence and associated sexual risk and pregnancy among adolescent girls in the United States. Pediatrics 2004; 114: e220–e225.

Black MC, Basile KC, Breiding MJ, et al. National intimate partner and sexual violence survey. Atlanta, GA: Centers for Disease Control and Prevention, 2011.

Silverman

McCauley

Decker

. Coercive forms of sexual risk and associated violence perpetrated by male partners of female adolescents. Perspect Sex Reprod Health 2011; 43: 60–65.

Allsworth

Anand

Redding

. Physical and sexual violence and incident sexually transmitted infections. J Womens Health 2009; 18: 529–534.

Alvarez

Pavao

Mack

. Lifetime interpersonal violence and self-reported Chlamydia trachomatis diagnosis among California women. J Womens Health 2009; 18: 57–63.

Teitelman

Tennille

Bohinski

. Unwanted unprotected sex: condom coercion by male partners and self-silencing of condom negotiation among adolescent girls. Adv Nurs Sci 2011; 34: 243–259.

American College of Obstetricians Gynecologists. Reproductive and sexual coercion. Committee Opinion No. 554. Obstet Gynecol 2013; 121: 411–415.

Decker

Miller

McCauley

. 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: 345–347.

Zierler

Cunningham

Andersen

. Violence victimization after HIV infection in a US probability sample of adult patients in primary care. Am J Public Health 2000; 90: 208–208.

10.

Ferreira

Young

Mathews

. Strategies for partner notification for sexually transmitted infections, including HIV. Cochrane Database Syst Rev 2013; 10. CD002843.

11.

St. Lawrence

Montaño

Kasprzyk

. STD screening, testing, case reporting, and clinical and partner notification practices: a national survey of US physicians. Am J Publ Health 2002; 92: 1784–1788.

12.

Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006.

13.

Golden

Whittington

Handsfield

. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med 2005; 352: 676–685.

14.

Schillinger

Kissinger

Calvet

. Patient-delivered partner treatment with azithromycin to prevent repeated Chlamydia trachomatis infection among women: a randomized, controlled trial. Sex Transm Dis 2003; 30: 49–56.

15.

Kissinger

Mohammed

Richardson-Alston

. Patient-delivered partner treatment for male urethritis: a randomized, controlled trial. Clin Infect Dis 2005; 41: 623–629.

16.

American College of Obstetricians Gynecologists. Committee opinion no. 518. Intimate partner violence. Obstet Gynecol 2012; 119(2 Pt 1): 412–417.

17.

Centers for Disease Control and Prevention. Guidance on the use of expedited partner therapy in the treatment of gonorrhea, www.cdc.gov/std/ept/GC-EPT-GuidanceNov-2012.pdf (2012, accessed 25 November 2014).

18.

Boyatzis

. Transforming qualitative information: thematic analysis and code development, Thousand Oaks, CA: SAGE, 1998.

19.

Elliott

Nerney

Jones

. Barriers to screening for domestic violence. J Gen Intern Med 2002; 17: 112–116.

20.

Association AM. Opinion 2.02: physicians’ obligations in preventing, identifying, and treating violence and abuse. Chicago: American Medical Association, 2008/2012.

21.

Moyer

. Screening for intimate partner violence and abuse of elderly and vulnerable adults: US Preventive Services Task Force recommendation statement. Ann Intern Med 2013; 158: 478–486.

22.

Wingood

DiClemente

Harrington

. Efficacy of an HIV prevention program among female adolescents experiencing gender-based violence. Am J Publ Health 2006; 96: 1085–1085.

23.

Jewkes

Nduna

Levin

. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ 2008; 337.

24.

Bennett

Riger

Schewe

. Effectiveness of hotline, advocacy, counseling, and shelter services for victims of domestic violence a statewide evaluation. J Interpers Violence 2004; 19: 815–829.

25.

Ullman

. Do social reactions to sexual assault victims vary by support provider? Violence Vict 1996; 11: 143–157.

26.

Miller

Decker

McCauley

. A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion. Contraception 2011; 83: 274–280.