William Fisher1, 2
(1)
Department of Psychology, University of Western Ontario, London, Ontario, Canada
(2)
Department of Obstetrics and Gynaecology, University of Western Ontario, London, Ontario, Canada
William Fisher
Email: fisher@uwo.ca
Keywords
Sexually transmitted infectionSexual dysfunctionCouple relationship
Sex therapists are in the business of restoring sexual function and enabling sexual behavior. Sexual behavior, however, may take place in the context of the risk of contracting a sexually transmitted infection (STI), the subjective fear of contracting an STI, the acute acquisition of an STI, or the chronic carriage of an STI, each of which may result in a cascade of negative effects on the couple’s sexual and relationship health.
Fisher and Holzapfel (2014)
Sexually transmitted infection (STI) concerns may profoundly influence the sexual and relationship health of the individual and the couple. This chapter reviews clinical scenarios in which STI issues may play an important role in the etiology, maintenance, and exacerbation of sexual and relationship dysfunction in the couple context. We explore the psychological and relationship impacts of STIs on individuals and their partners and consider counseling principles that may prove useful in working with men and women who are dealing with STI-related sexual and relationship problems.
34.1 Case Study
Cindy and Eric are in their late 30s and have been married for 5 years. They wish to have a child and have attempted to conceive for 6 months without result. Frustrated, the couple underwent fertility investigation and was advised that they will have difficulty conceiving due to tubal factor problems. They have been referred for IVF but are unsure about the invasive procedures, expense, and uncertain outcome. Cindy’s level of sexual desire, never strong, has waned, provoking conflict with Eric, further downward spiral in Cindy’s sexual interest, and her eventual complete withdrawal from sexual contact. Miserable, Cindy and Eric present at the sexual medicine clinic to seek help for what they conceive to be her problem with absent desire. As a routine part of Cindy’s individual interview, her physician asks, “Is there anything else I should know that might help me understand the issues you two are dealing with?” Cindy reports that when she was in college, she was diagnosed with chlamydia and treated for pelvic inflammatory disease. She adds that she has had deep pelvic pain since this episode, making intercourse uncomfortable, and that now, with tubal factor infertility, she feels she is “paying for past behavior.” Her husband is not aware of this history. As a routine part of Eric’s individual interview, the physician asks, “Is there anything else I should know that might help me understand the issues that you and your partner are dealing with?” Eric informs the physician that, since Cindy’s withdrawal from sex, he has had a one-time affair with a coworker. “I’m terrified I caught something. I’m terrified I’ll give her something! I want you to test me for everything. Now!”
As this case study illustrates, STI issues, individual, partner, or both and historical, concurrent, or both, may be of pivotal importance in the management of sexual and relationship dysfunction. Beyond case illustrations, systematic evidence concerning the impact of STI on sexual and relationship health has been reported, and relevant findings are considered in the section that follows.
34.2 Impact of STI on Sexual Function and Relationship Health
A number of general reviews of the impact of STI on sexual function have appeared in recent years [1–4]. Perusal of this work leads to a number of conclusions concerning the impact of STI on the couple. First, nearly all research concerning STI and sexual function focuses on the individual , not the couple, though there are very clear implications of STI impact on the individual that may reasonably be assumed to affect the sexual and relationship health of the couple. Second, there is very little population-based research concerning the association of STI and sexual dysfunction in representative national samples, although when such research is conducted, associations between STI and sexual function have been observed. Third, it appears that the sexual and relationship implications of infection with bacterial STI, which may readily be cured, may differ considerably from the implications of infection with viral STIs, which are not curable and which may result in chronic carriage and couple discordance of infection. Finally, it is often the case that clinicians who manage sexual dysfunction in men, women, and couples require “…a foundation of knowledge concerning STI prevention, prevalence, natural history, testing, treatment, and sexual and medical sequelae in order to be able to provide competent care in relevant situations” although this has not consistently been the standard of training or care in sex therapy or sexual medicine [1].
With respect to bacterial STI, a number of clinical issues are relevant. First, bacterial STIs, including chlamydia and gonorrhea, are often asymptomatic, and may be detected, to the potential shock and surprise of the individual, in the context of screening as opposed to symptomatic presentation [5]. Given asymptomatic carriage over varying periods of time, issues of the source of infection and transmission to sexual partners may be ambiguous [6, 7], and caution is warranted in relation to false-positive screening results in low prevalence populations [4, 7]. What is not in doubt, however, is occurrence of the negative impact of bacterial STI on the individual and often by extension on the couple. Gottleib et al. [7] enrolled 1807 women who were undergoing routine chlamydia testing as part of family planning clinic appointments, some 8.8 % of who tested positive for infection. At 4- to 6-week follow-up, chlamydia-positive women showed a 75 % increase from baseline in anxiety about sexual aspects of their life on a validated survey instrument. Nearly all of the women (99 %) who tested positive for chlamydia were worried that they could have been exposed to other STIs, 87 % felt it would be difficult to trust future partners, more than 75 % stated that they were “not very proud of their actions,” more than two-thirds felt betrayed by their partner, and substantial numbers of chlamydia-positive women were angry, afraid to tell their partner, and concerned about future fertility. At follow-up, three times as many chlamydia-positive women as chlamydia negative had broken up with their relationship partner. Duncan et al. [6] report similar findings for self-disgust and anxiety about the male partner and concern about future fertility in qualitative research with a smaller sample of women who tested positive for chlamydia. We note that a history of chlamydia or other bacterial STI may serve as a predisposing factor in future development of sexual and relationship dysfunction precipitated by contemporaneous events. We note as well that diagnosis of chlamydia or other bacterial STI, whether as the result of screening and identification of past infection or acute symptomatic presentation of current infection as a result of extra-relationship sexual contact, may precipitate relationship crisis [1].
With respect to the impact of viral—and therefore manageable, but not curable—STI, research concerning the impact of herpes simplex virus (HSV), human papillomavirus (HPV), and human immunodeficiency virus (HIV) on sexual and relationship health is informative. Sexual and relationship impact of viral STI infection may stem from the infection and its clinical symptoms; anxiety about chronic carriage of the virus; concerns about transmission of the virus to or from a sexual partner or during childbirth; extended, painful, and sometimes ineffective treatment of symptoms; and direct iatrogenic impact of pharmacotherapy of the infection [4, 8–10].
Mindel and Marks [3] have reviewed the literature concerning the psychosexual impact of HSV infection, noting that genital herpes is a common, chronic, and recurrent challenge. Within the limitations of existing research—which include focus on clinical samples and lack of controls—it appears to be the case that individuals with herpes may experience depression, anger, diminished self-esteem, hostility toward the partner perceived to be the source of infection, and fear of transmission to others. Research suggests that individuals experiencing a first episode may be particularly affected, while individuals who have lived with HSV for a length of time may have learned to cope with it better, but at the same time, those with recurrent HSV outbreaks may continue to experience psychosexual challenge at significant levels. Mindel and Marks [3] review directs special attention to the availability of serological testing for HSV and to the potential for psychosexual morbidity among those testing positive who have no history of herpes infection. In this connection, Melville et al. [11] conducted qualitative research with 24 individuals who tested positive for HSV-2 and who had no clinical history of disease. Short-term emotional responses to the herpes diagnosis included surprise, distress, and self-blame, and importantly, long-term concerns included worries about partner acceptance, concern about transmitting HSV infection to the partner, feeling sexually undesirable, feeling like damaged goods, avoidance of sex, and relationship problems after diagnosis. Mindel and Marks [3] suggest that management of psychosocial consequences of HSV infection can include rapid diagnosis, accurate information about the infection and its consequences, strategies for reducing the risk of transmission to others, advice about antiviral suppressive treatments to limit recurrence, and psychological support, including cognitive behavioral therapy to alter affected individuals’ way of thinking about herpes and means of coping with the infection. Online support and community-based support groups are also available [12].
Studies of the psychosexual impact of HPV infection have appeared both before [9, 13] and after [14–18] availability of HPV vaccine protection and movement toward routine HPV DNA screening as a cervical cancer screening approach [5, 19]. From the perspective of challenge to couple sexual and relationship health, it is important to note that HPV infection is exceedingly prevalent, it may spontaneously clear or remain chronic, and it may be asymptomatic or result in the appearance of genital warts (low-risk HPV types), cervical dysplasia and cervical, vulvar, oropharyngeal, penile, and anal cancer (high-risk HPV types) [5]. HPV infection may also be transmitted from mother to infant, though rarely, resulting in recurrent pharyngeal papillomatosis [20].
The occurrence of each of the pathological sequelae of HPV infection—as well as worry about the possible future occurrence of these outcomes—may predispose, maintain, or exacerbate sexual and relationship problems. Graziottin and Serafini’s [15] review of psychosexual consequences of HPV infection highlights challenges that include depression, anxiety, and anger, feeling worse about one’s sexual relationship, concern over “who infected who,” and sexual problems specifically associated with HPV-related genital warts and their repeated and painful treatment. Individual studies of psychosexual impact of HPV diagnosis may be particularly informative. For example, Daley and colleagues [14] examined the effect of HPV infection in a sample of HPV-positive women who attended routine gynecological examinations that included Pap tests that, if abnormal, were followed up with HPV DNA testing. Findings revealed impacts of HPV infection that have significant implications for couples’ sexual function and relationship health, including stigma (70 % of HPV-positive women worried that people would judge them), shame (68 %), feeling that they are paying for past behavior (68 %), feeling “unclean” (59 %), and reporting that “having HPV in my body is disgusting to me” (55 %). Drolet et al. [21] evaluated the psychological status of a large group of women who received abnormal cervical smear results indicative of HPV infection compared to a control group of women with normal cervical smears. Findings indicated both immediate and sustained impact of abnormal cervical smear results on women’s anxiety level and on each measured dimension of an HPV Impact Profile [22] including emotional impact, self-image, sexual impact, and concern about partner and transmission issues. In related research, Drolet et al. [17] examined the psychosexual reactions of men and women who were undergoing treatment for HPV-related genital warts. Findings indicated significant elevations in anxiety and depression, pain and discomfort, and multiple dimensions on the HPV Impact Profile [22] including sexual activity, worries about partner and transmission of infection, and self-image. Negative impacts of HPV-related genital warts persisted for as long as the warts persisted. Notably, at 6-month follow-up, 51 % of participants—all of whom had received treatment—still had genital warts and elevated psychosexual challenge. Findings indicated similar negative psychological and sexual impact on men and women and similar impact from initial compared to recurrent episodes of genital warts. Also of relevance to sexual and relationship health of the couple are findings concerning disclosure and nondisclosure of HPV infection to a partner, although the efficacy of partner disclosure for prevention of transmission has not been demonstrated [23]. Some 66 % of HPV-positive women in Daley et al.’s [14] research indicated that they would disclose their HPV status to a future sex partner (though at the time of participation in this research, only 39 % had actually informed their partner) and 26 % were unsure about whether they would disclose their HPV infection to their partner. In an interesting parallel, Arima et al. [18] enrolled university student men in a longitudinal study, testing periodically for incident HPV infection and assessing whether men with incident infection disclosed this to their partner. Men with incident HPV infections reported disclosing to their partner in 31 % of affected partnerships.
As cervical cancer screening moves toward routine reliance on HPV DNA testing [19], it is critical to note that a substantial proportion of midlife women will test positive for HPV infection at midlife as the result of chronic carriage of much earlier infection [1, 5]. HPV diagnoses may thus be expected to increase substantially in future years with a corresponding increase in negative sexual and relationship impact on the couple. Specific illustration of sexual and relationship impact of an HPV diagnosis is provided in a venerable study by Campion and colleagues [13]. These investigators evaluated women who had HPV infection, with or without cervical intraepithelial neoplasia (CIN). Compared to controls, women with HPV infection or HPV and CIN reported substantial declines in spontaneous sexual interest, frequency of intercourse, adequacy of vaginal lubrication and sexual arousal, frequency of orgasm, and a substantial increase in painful intercourse. Critically, with respect to relationship health, women with HPV infection or HPV and CIN reported a substantial increase in negative feelings about sexual intercourse with their current partner or (if there was no current partner, toward intercourse in general), compared to controls. McCaffery and colleagues [16] report similar negative impact of HPV infection on feelings about sexual partners: “…HPV+ women demonstrated significantly greater concerns about their sexual relationships than women who tested HPV−…These findings are suggestive of a marked negative impact on feelings about sexual relationships among women who were HPV+” [16].
To provide some balance to this litany of negative effects of STIs on sexual and relationship health, we note that close reading of the literature suggests there may also be reasons for some degree of optimism. Clinical case reports of the management of HPV infection [9] indicate that specific clinical care steps—including crisis management upon diagnosis, if necessary; supportive counseling to empower the patient to take an active role in managing their infection and avoiding transmission; and clinical education concerning optimal medical follow-up—may represent a comprehensive approach to facilitating better outcomes over the longer term. Clearly, in relevant cases of affected couples, couple counseling could be added to this mix at each level of crisis management, empowerment, and education of patient and partner. Other reasons for a measure of optimum have surfaced as well [14]. Daley et al. [14] found that—in addition to multiple negative impacts of HPV diagnosis—some 52 % of women diagnosed with HPV reported feeling closer to their partner. Drolet et al.’s [17] report that within the broadly negative impact of an abnormal cervical smear on quality of life, anxiety, and sexual functioning and partner and transmission concerns, significant improvements were observed in each of these indicators at a 12-week follow-up interval, although each was still negatively impacted compared to controls. Drolet et al. [21] also report that the negative impact of anogenital warts resolved among the roughly 50 % of their affected sample of men and women whose warts were no longer present at follow-up. These findings for improvement with comprehensive and appropriate clinical care, time, and treatment progress may provide the basis for a measure of evidence-based optimism that can be conveyed to affected patients and partners.
HIV infection may represent an extreme version of the impact of chronic carriage of viral STI on couple sexual and relationship health. HIV infection is associated with sexual dysfunctions in men, including erectile dysfunction and low sexual desire [8, 24], as well as in women [25–27], for reasons that include the effects of HIV infection on sexual function; the effects of HIV antiretroviral (ARV) therapy on sexual function; the effects of HIV and ARV on body fat distribution, body image, and perceived attractiveness; HIV stigma; HIV-related depression; the HIV concordance or discordance of the couple; and the fear of transmission to others. As is the case with other STIs, individual and couple management may benefit from clinical education, treatment of HIV disease, and counseling concerning reduction of transmission risk, which in the case of HIV will involve adherence to ARV therapy, achievement of undetectable viral load, and consistent use of condoms. We note that meta-analytic evidence exists to support the effectiveness of cognitive behavioral therapy in improving the psychological health of HIV-infected individuals [28].
34.3 Counseling Principles at the Intersection of STI and Couple Sexual and Relationship Function
This review has considered a wide array of systematic evidence concerning the effect of STIs on an individual’s sexual health and on the couple sexual relationship. We conclude with suggestions for management of couples whose sexual and relationship health is challenged by STI-related issues [1].
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