Women with viral STIs face dilemmas in negotiating condom use and would like direct safe sex advice from clinicians
- Correspondence to: C Ann Gakumo, PhD, RN
School of Nursing, Acute Health, Chronic Care & Foundations Dept., Birmingham, AL 35294-1210, USA;
Commentary on: Cook C. ‘Nice girls don't’: women and the condom conundrum. J Clin Nurs 2012;21:535–43.
Implications for practice and research
Sexual health counselling should extend beyond basic educational information to address contextual factors women face in partner relationships.
Because nursing practice centres on the patient–clinician relationship, feminist post-structuralist designs are effective at addressing power dynamics faced by vulnerable populations, further fostering communication between women and clinicians and improving women's sexual health.
The study highlights experiences of high-risk women in communicating condom use with their partners and discussing with healthcare providers the impact of a sexually transmitted infection (STI) on their intimate relationships. Clinicians’ views on the effective sexual health communication with their female patients were also examined. The study focused on women diagnosed with genital herpes simplex virus (HSV) and human papilloma virus (HPV). Global estimates of HSV in people aged 15–49 is 536 million worldwide and women are disproportionately infected (315 million vs 221 million in men).1 In addition, the prevalence of HPV in women worldwide has been estimated to be as high as 11.4%.2
The sample included 26 women with HSV or HPV and 12 clinicians with experience in sexual/gynaecological health. The study was based in New Zealand, but international in scope, as the sample included participants from New Zealand, the USA, Canada, the UK and Australia. Data were collected via email interviews with repeated correspondence. Thematic analyses revealed major themes related to condom use, feminine sexuality and societal norms.
Most women did not discuss safer sex with their partners before STI diagnosis and of these, most found it difficult to discuss safer sex with their partners postdiagnosis. Women who discussed safer sex prediagnosis with their partners were more likely to have this conversation after diagnosis. Some women either avoided sexual activity altogether postdiagnosis (n=3) or continued sexual activity, but did not discuss safer sex (n =2). Rarely did clinicians advise female patients beyond basic education on contextual factors such as STI disclosure, condom negotiation skills, or power dynamics in a sexual relationship.
A feminist poststructuralist design framed the study as it was confined to exploring the discourse of STIs and feminine sexuality on condom use. A tenet of poststructuralist theory is that competing discourses lead to a variety of truths in any one context.3 The discourse highlighted in the study was one of feminine social norms conflicting with a woman's ability to initiate safer sex.
As an exploratory study, it was limited to the subjective views of 26 individual participants who responded to a web-based advertisement. The ages of the women varied widely (22–71 years) and most were of European descent. Although one researcher analysed data, themes were critiqued by an additional independent researcher to enhance reliability of findings and conclusions.
The study supports previous studies examining the difficulties women face in negotiating condom use such as passivity and unequal power dynamics in a sexual relationship.4 ,5 This study notably explored women's subjective experiences regarding condom use after being diagnosed with an STI. It also addressed the clinician's need to broaden sexual health talk beyond mere educational information. Because relationships are a central focus in nursing practice and those who seek healthcare are often marginalised, nurses are in a unique position to incorporate sexual health teaching that is gender-specific, empowering and contextually appropriate. A systematic review of randomised control trials of STI prevention interventions for young women found that the majority of interventions provided skill-building in partner sexual communication.6 Overall, the interventions were found to be significant for increasing condom use, but not for increasing abstinence or decreasing sexual activity. Future work in sexual communication should have increasing condom use as a central focus in behavioural change. Furthermore, it is recommended that nurses’ training in the implementation of condom negotiation strategies will facilitate an ongoing client–nurse partnership to promote positive-sexual health outcomes for the long term.