Volume 6 - Number 2 1997
Special Issue: STDs and Sexual/Reproductive Health

Published by SIECCAN
The Sex Information & Education Council of Canada

Reducing the Incidence of Sexually Transmitted Disease Through Behavioural and Social Change

Eleanor Maticka-Tyndale
Department of Sociology & Anthropology
University of Windsor
Windsor, Ontario

Abstract:

Sexually transmitted diseases (STDs) pose a threat to the general health, well-being, and reproductive capacity of a sizeable number of Canadians. Individual STD risk varies according to age, sex, ethnicity, and geographic location. This paper addresses the behavioural and social changes that may lead to a reduction in the incidence of STDs in Canada. Canadian research on number of sexual partners, age of first intercourse, condom use, and the availability and use of STD diagnostic and treatment facilities is reviewed. Increasing condom use and access to STD diagnostic and treatment facilities are identified as the most efficacious targets for effective STD prevention programming. Surveillance, research, policy and program needs are identified.

Keywords:

• STD prevention, Canada, Behavioural change, Condom use

Acknowledgements:

Thanks to Michelle Coghlan for assistance with the literature search, Dr. Sandra Houston for locating data and providing commentary and Dr. Sean Lake for providing population adjustments on NPHS and CHM data.

Correspondence concerning this paper should be addressed to Dr. Eleanor Maticka-Tyndale, Department of Sociology & Anthropology, University of Windsor, Windsor, Ontario, N9B 3P4

Introduction

Although the overall rates of some sexually transmitted diseases (STDs) such as chlamydia (e.g., Patrick, 1997), syphilis (e.g., Romanowski, 1997), and gonorrhea (e.g., Alary, 1997a) are decreasing, they remain an ever present threat to the general health, well-being, and reproductive capacity of a sizable number of Canadians. The number of reported cases of STDs in Canada likely represents only a fraction of actual cases since many instances of reportable STDs go undetected, and some of the most common STDs, such as human papilloma virus (HPV) and herpes simplex virus (HSV), are not reported to public health authorities. Drug therapies can provide cures for some STDs but not for others (i.e., HPV, HSV) (Lytwyn & Sellors, 1997; Steben & Sacks, 1997). Reproductive health problems, including pelvic inflammatory disease (PID), are the frequent result of undetected and untreated STD (e.g., Macdonald & Brunham, 1997). HIV/AIDS poses a major health threat to Canadians, with the annual frequencies of adult AIDS cases continuing to rise in all geographic regions and among all risk groups except recipients of blood transfusions and clotting factor (Health Canada, 1996). Although Laboratory Centre for Disease Control calculations indicate that the incidence of HIV infection probably peaked in Canada in the early 1980s, there appears to have been a recent acceleration of HIV infections that began in 1990 (Frank, 1996).

Although all sexually active individuals risk exposure to STDs, levels of risk vary, as is evident in differential rates of infection based on age, sex, ethnicity and geographical region. For example, in general, the rates of infection are highest among those who are younger, among women, and in the Northwest Territories. In addition, there are specific "pockets" of high infection among certain population groups such as those of lower socio-economic status, native peoples and street youth.

The dilemma, as well as the solution, of reducing new instances of sexually transmitted infection is captured in the mathematical equation Ro=ccD which expresses the reproductive number or reproductive rate for infectious diseases (see Brunham & Plummer, 1990). The reproductive number or reproductive rate (hereafter referred to as Ro) is the mean number of new infections generated by infected persons over the lifetime of their infection (in a fully susceptible population). The phrase in brackets means that the infected person is encountering new uninfected partners who would not have been exposed except through him/her. (ß) is the probability of transmission from an infected to an uninfected person, (c) is the contact rate between infected and susceptible individuals, and (D) is the average duration of infectivity of infected individuals. The ultimate goal is to reduce Ro to below 1. All three of the co-factors that influence Ro have behavioural and social components. The number of contacts, ß, is influenced by the number of sexual partners, and mixing between sexual networks (i.e., patterns of sexual behaviour within population subgroups). Risk of transmission, c, is influenced by the forms of sexual activity people engage in (e.g., vaginal or anal penetration vs. non-penetrative sex), including the use of condoms. The duration of infectivity, D, is influenced by the availability and use of diagnostic and treatment facilities that can either eliminate or reduce infectivity. Thus, to lower Ro and thereby reduce new instances of STDs in the Canadian population, we must address the social and behavioural changes that can produce such a reduction.

Canadian Research on the Social and Behavioural Correlates of STDs

In order to make effective use of the Ro=ßcD equation both to conceptualize the spread of STDs and to design programs and policies to reduce the spread, it is necessary to understand the components of the equation. Unfortunately, we have little Canadian data on which to draw conclusions about the relationships between sexual partnering, sexual acts, condom use, and the use of diagnostic and treatment facilities. Similarly, we know little about the relationship of these factors, alone or in combination, to the distribution of STDs between and among subgroups of the Canadian population. Our sparse information comes from a small number of national studies that were designed to maximize generalizability to the Canadian population and its subgroups, but not necessarily to focus on salient components of Ro=ßcD. We do have information from a number of small local studies although their generalizability is questionable. Nevertheless, the available data can be used to identify the social and behavioural factors which, when targeted for change, may lower the incidence of STDs in Canada. This paper reviews research on number of sexual partners and age of first sexual intercourse, both of which are considered to be indicators of the contact rate between infected and susceptible individuals (c), and on condom use, which is considered to be an indicator of the probability of transmission from an infected to a susceptible partner (ß).

Three national health surveys done by Health Canada, the National Population Health Survey (NPHS) conducted between December, 1994 and January, 1995, and the Canada Health Monitors 1994 and 1995 (CHM94 and CHM95), provide the most recent national data on sexual behaviours. However, the form and content of questions addressing sexual behaviours in these surveys did not always provide data directly relevant to the Ro=ßcD equation. For example, the absence of questions on lifetime number of sexual partners and the use of broad age categories impede the development of a profile of relevant social and behavioural factors. The Canada, Youth and AIDS study (CYA) (King, Cole & King, 1990) conducted in 1988 is used to provide information about youth in the late 1980s. It includes detailed information on sexual behaviours and self-reports of STD history and can be used to examine behavioural clusters. However, the data collected relevant to decision-making around STD risk have not been fully analysed; this limits the conclusions that can be drawn based on the study.

Three studies funded under the National AIDS Strategy provide information for specific population subgroups. These include the First Nations (FN) study conducted in 1990-1991 (Myers, Calzavara, Cockerill, Marshall, & Bullock 1993), the Men Who Have Sex With Men (MSM) study conducted in 1991-1992 (Myers, Godin, Calzavara, Lambert & Locker, 1993) and the Ethnocultural Communities Facing AIDS (ECFA) study conducted in 1991-1994 (Maticka-Tyndale et al., 1996). The FN study included eleven First Nations communities in Ontario with a total sample of 658 individuals. The MSM study was Canada-wide, and drew from gay-identified venues for a sample of 4,803 gay-identified men. The ECFA questionnaire sampled 362 to 375 individuals from each of three ethnocultural communities (English-speaking Caribbean, Latin American, South Asian) using stratified prposive sampling from ethnocultural venues and organizations. The nature of the population subgroups covered in these studies made it impossible to follow sampling procedures that could guarantee the representativeness of the sample; however, these studies provide the best data available on several specific population subgroups. Finally, the results of a variety of smaller scale studies collectively provide indications of the sexual practices of interest and, in particular, how they fit into the STD picture. Again, the sampling strategies and targeted populations were local and do not support Canada-wide generalization. The availability of these data is in large part due to funds provided through the National AIDS Strategy. The absence of better data is associated with the general absence of funding for high quality, large scale studies of sexual behaviours and the exclusion of salient questions on sexual behaviours from national surveys prior to the National AIDS Strategy.

Contact Rate Between Infected and Susceptible Individuals (c)

Number of Partners and Sexual Networks

The number of sexual partners is considered a prime indicator of the contact rate between infected and susceptible individuals. When a given element (e.g., an STD) is randomly distributed in a population and transmission-appropriate contacts among members are random, there is a positive association between the number of contacts and the spread of the element in the population. However, neither STDs nor sexual couplings are distributed randomly. In subgroups with low STD rates, influencing the number of sexual partners that group members have will have minimal, if any, impact on the rate of STDs. Even in geographical regions with high STD rates, there will be little transmission of STDs between population subgroups in those regions if they do not have overlapping sexual networks. Targeting the number of sexual partners as a mechanism for reducing the rate of STDs requires identification of the specific population subgroups with high rates of STDs and high numbers of partners, identification of the patterns of sexual networking within those subgroups, and determination of the links or bridges between these subgroup networks and other subgroups that may have lower rates.

Data on Number of Partners and Sexual Networks

Little is known about trends in the lifetime number of sexual partners of Canadians or about the relationship between lifetime number of partners and such variables as: age of first intercourse; age of first marriage; socio-economic, demographic, and cultural characteristics; geographical region; or history of STDs. Even less is known about the sexual networks of population subgroups. Studies of sexual behaviours done prior to the late 1980s were concerned merely with the presence or absence of premarital sexual intercourse, unintended pregnancy, and their correlates, with little data collected on number of partners (e.g., Crepault & Gemme, 1975; Herold, 1984; Hobart, 1972, 1975). Research since the late 1980s has identified the contemporary normative pattern for sexual relationships as one of serial monogamy, particularly among young women. For those who are sexually active, such a pattern typically results in a population modal number of one partner in any one year period (Table 1). However, recent research also suggests that for some young adults, a pattern of multiple casual sexual partnerships is interspersed between or engaged in coincident with an existing "primary relationship" (e.g., Herold & Mewhinney 1993; Maticka-Tyndale & Herold 1997). It is not known how common these alternative patterns or scripts are, what their age or geographic spread is, or how they might contribute to cross network sexual encounters. This combination of patterns of sexual contact (serial monogamy and casual contacts) produce Poisson distributions for both the total number of lifetime sexual partners and the number of partners in any designated time period. Most individuals cluster at the low end, while those with multiple casual partners produce the tail of the distribution. It has been suggested that it is the sizeof the tail of this distribution that determines and drives the spread of STDs.

In the NPHS and CHM94 studies (Table 1), sexually active men and women of all ages most commonly reported only one sexual partner in the past year (no information was collected on lifetime number of partners). The proportions of men and women who reported more than one partner in the past year decreased with age. The common assumption that the lifetime number of sexual partners does not rise much after marriage*** is consistent with these data.

In the CYA study, respondents reported the number of total lifetime partners (Table 2). The number of partners was positively associated with school grade (and consequently with age). The oldest respondents in this study were first year college and university students. Among those in this group with sexual intercourse experience, 27% of males and 15% of females reported 6 or more lifetime partners. The proportion with 6 or more partners was highest for school dropouts (48% of males and 30% of females) and street youth (65% of males and 58% of females). This is an important consideration since these youth, having broken their ties with the school system, are the hardest to reach with sexuality education or health services. The proportion self-reporting a history of STDs was positively associated with the number of sexual partners, but was highest in each instance for street youth, thus suggesting that factors other than the number of partners were salient to self-reports of STDs. The ECFA study also found variability among ethnocultural communities in the correlation between number of partners and self-reported STD history (Maticka-Tyndale et al., 1996). Consistent with the greater susceptibility of women to sexually transmitted infection, a higher percent of women than men in CYA reported a history of STDs, though women had somewhat fewer partners at each age than had men (King et al., 1990). In ECFA, the number of partners varied by community and age; here too, women reported fewer partners than men, although their self-reported STD histories were similar (Maticka-Tyndale et al., 1996).

In the absence of more detailed analyses, it is impossible to identify any patterns or population subgroups beyond the very broad age group of those under 30 years of age who are important for targeting with programs designed to reduce the number of sexual partners. The three recent studies of specific population subgroups (ECFA, FN and MSM) (Table 3), as well as a multiplicity of smaller-scale studies, all support the conclusion that there are pronounced variations in the number of sexual partners across different population subgroups and sexual scripts. These may or may not correlate with STD rates. If appropriate behavioural targets are to be set, we need more detailed analyses that examine: the relationships between number of partners, marital status and years since first sexual intercourse; the shape and dynamics of the association between number of partners and STD rates; the features of these factors in specific population subgroups; and the sexual scripts that produce variations in number of partners and relationships between partners. Research on sexual networks, particularly among and between population subgroups or communities with different rates of infection, would also make a substantial contribution to our understanding of influences upon, and ways to influence, sexual partnering.

For example, information from the qualitative research phase of ECFA suggests that in some communities, sex prior to marriage is highly valued for men, but not for women. To maintain this double standard, men have partners from outside the community. This produces overlapping sexual networks, with men as the bridge between the marital sexual relationships in one community and non-marital relationships in another. The young in these communities may have different rates of STDs. The major route of STD entry into the original ethnocultural community appears to be through young mens sexual contacts outside the community prior to marriage, and transmission to their new wives. Given the cultural value on males sexual experience and the low number of sexual partners that women have, a target of reduction in the number of partners woul be both difficult to realize and not the most effective method to reduce STDs in this community. Since this community (as do many) makes a distinction between those within, who are seen as most trusted, treasured and "clean", and those without, who are seen in a less favourable light, a more effective and realizable target might be to increase condom use with partners from outside the community. An alternative or additional strategy is premarital testing of men for STDs in communities with these behavioural and cultural characteristics. Without this type of analysis, the appropriate behavioural target cannot be determined.

***The Canadian average age of first marriage is 26 for women and 28 for men. There are wide variations with region, ethnocultural group, socio-economic status, education, rural/urban, etc. (Vanier Institute, 1994).

Age of First Intercourse

Age of first sexual intercourse has been cited as a potentially relevant factor in reduction of STD transmission, both because it is associated with number of lifetime partners for both sexes and because of the greater vulnerability to infection among young women. Correlational studies conducted in the United States demonstrate strong correlations between age of first sexual intercourse and both lifetime number of partners and number of STDs. Based on these findings, age of first intercourse is often considered a salient behavioural target for reducing STDs. However, there have been no data collected in Canada similar to those in the United States. In addition, results of some research suggest that women who engage in first sexual intercourse within a year of menarche may be biologically more vulnerable to at least some STDs. Again, the research is suggestive and does not demonstrate a clear relationship between age and biological vulnerability (e.g., Shew, Fortenberry, Miles, & Amortegui 1994).

Data on Age of First Intercourse

Studies conducted between 1974 and 1995 in Canada (Table 4) suggest that the proportion of young men who report sexual intercourse by Grade 9 (approximately 15 years of age) has remained relatively stable. For young women, the proportion reporting sexual intercourse by Grade 9 has, following an earlier increase, decreased in the most recent years. This pattern is repeated for young women in Grade 11 (approximately 17 years of age), though the proportions of young men reporting sexual intercourse by this age has recently increased. Although at first glance the gender differences appear anomalous, number of partners, geographical locale of partnership, subgroup from which the partner comes, and crossovers between sexual networks must be examined to understand the nature of these young sexual partnerships.

What is apparent from the most recent data is that the majority of Canadian men and women initiate sexual intercourse between 16 and 19 years of age (see Table 5). Unfortunately, the use of broad age categories (i.e., 15-19 years) or of indirect questions in the national studies makes it difficult to be more precise about the age of first intercourse.

Research from small-scale studies and studies in the United States suggests that it is initiation of sexual intercourse at the very youngest of ages (i.e., under 15 years, and in particular 13 years and younger) that carries an unequivocal burden of elevated STD rates. Studies have further demonstrated strong correlations between sexual initiation at these youngest ages and a multiplicity of antecedent, concurrent, and later health and social problems including: sexual coercion (e.g., Lindsay & Embree, 1992; Miller, Monson & Norton, 1995; Bajracharya, Sarvela & Isberner, 1995); "street" involvement (e.g., King et al., 1990); use of sex for survival (e.g., King et al., 1990); minority economic and ethnic status (e.g., Maticka-Tyndale & Levy, 1992); alcohol use (e.g., Dorius, Heaton & Steffen, 1993; Graves 1995); and multiple risk-taking behaviours (e.g., Coker et al., 1994; Ku, Sonenstein & Pleck, 1993).

While condom use is less likely in first intercourse when the partners are younger, those who are younger report higher rates of condom use overall (see Table 6), or in the last sexual encounter. The data on condom use and the factors influencing the very youngest age of first intercourse suggest that it is not age per se which carries heightened risk for STDs, but rather the ful social context within which the very youngest intercourse often occurs. Targeting age in itself would not necessarily have the desired effect of decreasing STDs.

Probability of Transmission from an Infected to an Uninfected Person (ß)

There are both biological and behavioural aspects to the probability that infection will occur in the case of sexual contact between a susceptible and infected partner. Biologically, different STDs have different degrees of infectivity (cf. hepatitis B and HIV), and different modes of transmission (cf. syphilis and gonorrhea). Women are biologically more susceptible to infection than men. Behaviourally, different sexual acts carry different degrees of risk for infection (cf. penetrative vs. non-penetrative activity), and the use of condoms, other latex barriers, or viricides can impede many sexually transmitted infections. The interaction between the biological and behavioural elements is evident in studies that demonstrate that for less easily transmissible STDs, small increases in condom use reduce the incidence of new infection; whereas, for more easily transmissible STDs, shifts to more regular condom use are required to reduce the incidence of new infection (e.g., Stigum, Magnus, Veierod, & Bakketeig, 1995). For some STDs, condom use may have a negligible effect on transmission, since transmission may occur through a variety of forms of contact (e.g., HPV, hepatitis B). In addition, while women are at greater risk of infection from a sexual partner than are men, until a female condom is readily available, a woman can only try to influence her male partner(s) to use condoms, as opposed to her using them herself. While some research on women (typically university students) has demonstrated strong associations between intentions and use of condoms, womens intentions may be influenced by factors such as fear of coercion, force or abandonment (e.g., Holland, Ramasanoglu, Scott, Sharpe & Thomson, 1992 for non-university women in the UK; Maticka-Tyndale et al., 1996 for minority ethnic women in Canada; Sobo, 1995 for inner-city women in the United States). Recent research suggests a history of force or coercion has similar negative influences on condom use for both men and women (e.g., Veiel, 1995; Weinrich, Atkinson, McCutchan, Grant, 1996). Finally, there has been little research on factors associated with the choice of non-penetrative alternatives to sexual intercourse as methods to decrease transmission. Most of the focus on prevention of STDs has been on condom use.

Data on Condom Use

With the introduction of oral contraception, condom use declined in Canada. However, since the late 1980s, condom use has increased. In general, the more recent the study, the higher the proportion of people reporting condom use. This is an encouraging and perhaps expected trend given the importance attached to condom use in AIDS prevention programming. Overall, the available data suggest that condom use is increasingly viewed as a normative behaviour. Indeed, the growing perception of condom use as a socially responsible norm has cued some researchers to become more attentive to ways of detecting normative bias in responses to surveys about condom use (Maticka-Tyndale & Herold, 1997). There is anecdotal speculation about such a bias, but no published evidence that it exists.

NPHS and CHM94 data demonstrate that condom use is most frequent for those who have more than one partner, in sex with "non-regular" partners, and for those who are younger (see Table 6). This pattern was also seen in all communities participating in the ECFA study. However, the ECFA also demonstrates ethnic variationsin condom use.

Once condoms were recognized as an effective method to reduce the spread of HIV, research attention focused on factors that influenced their use. Two consistent findings are that oral contraception and being in a self-defined monogamous relationship are impediments to condom use (e.g., Fisher, 1989; Maticka-Tyndale, 1991). In addition, it appears that condom use for purposes of disease prevention follows a script much like that for pregnancy prevention (Fisher, 1989). Condoms are used at the beginning of relationships or in casual encounters, particularly when this is acceptable to or suggested by the partner (e.g., Maticka-Tyndale & Herold, 1997; Otis et al., 1990). As partners become better known to each other, condoms are less likely to be used since both feel a sense of trust and safety that there is no danger from STDs. Serial monogamy contributes to a sense of invulnerability to STDs since each partner is an "only" partner and the relationship between partners is accompanied by emotions and attitudes of trust, love and concern for the partner, all of which override self-interest (Byers, 1991; Fisher 1989; Maticka-Tyndale 1992).

Studies conducted under the umbrella of AIDS research have elaborated the social, cultural and psychological factors associated with condom use and the interplay between them. This knowledge has been used to design programs and strategies such as Fisher and Fishers Information-Motivation-Behaviour Skills program (J.D. Fisher & Fisher, 1992; W.A. Fisher & Fisher, 1992), and the condom and pill campaigns targeting physicians, pharmacists and female patients undertaken by Calgary Health Services (Wong-Reiger, LaBrie, Guyon & Smith, 1996). This research, together with more broadly-based research on the development of sexuality, helped set the foundation for the Canadian Guidelines for Sexual Health Education (Health Canada, 1994) and for sexuality education programs such as Skills for Healthy Relationships (Warren & King, 1994) developed by the Social Program Evaluation Group at Queens University. Evaluation of this educational program and others like it has led to the conclusion that such programs lead to significant increases in condom use, decreases in the number of partners, and postponement of first sexual intercourse (Baldo, Aggleton & Slutkin, 1994 ; Kelly, 1995; Warren & King, 1994), all desirable sexual health outcomes.

Duration of Infectivity (D)

Decreasing the duration of infectivity is the remaining element in the equation defining the reproductive rate of STDs. The duration of infectivity of an STD is the product of the interaction between biological, social and behavioural factors. STDs have their own biological life course, duration, and cycle of infectivity. However, for many STDs, diagnosis and treatment can shorten this duration, thereby reducing the likelihood of disease transmission to an uninfected partner. Diagnosis and treatment have both social and behavioural components. Availability and normalization of diagnosis and treatment are two social components that influence the duration of infectivity. Seeking out diagnosis and compliance with treatment regimens are two of the behavioural components that influence the duration of infectivity. Ensuring client access to STD diagnosis and treatment is also a necessary component in reducing the duration of infectivity.

Little research has been done on the factors influencing individuals to seek out diagnosis and treatment of STDs, the factors influencing health care practitioners to initiate discussion, counselling, diagnosis and treatment of STDs, or on the availability and nature of diagnostic and treatment facilities. The potential benefit of increased accessibility is demonstrated in the results of Orton and Rosenblatts (1991, 1993) Ontario study of adolescent pregnancy rates. Access to clinics that provide sexual health counselling and services was associated with a significant decrease in adlescent pregnancy rates. However, data from Quebec suggest that merely having treatment facilities available does not guarantee their use. Though there are nearly twice as many cases of STDs reported for Quebec women than men (1.76:1 in 1994, 1.84:1 in 1995) fewer women than men (0.88:1 in 1994, 0.95:1 in 1995) receive free STD treatment through provincial programs (Parent & Alary, 1996; Alary, 1997b). The report of the Royal Commission on New Reproductive Technologies (1993), and other research, suggest that accessing and using diagnostic and treatment facilities varies with: socioeconomic status; age; race and ethnicity; gender; geographical region; location on the rural to urban continuum; sexual orientation; presence, type and persistence of symptoms; sexuality education; prior experience with STDs; organization of health care delivery locally, provincially and nationally; and location of sexual health services. In addition, reports from treatment facilities also highlight the importance of using single dose treatments whenever possible to avoid problems with treatment non-compliance (e.g., Patrick, 1997).

Social and Behavioural Goals

Based on this review, two behavioural factors appear to be efficacious targets for reducing the incidence of STDs: an increase in rates of condom use and an increase in access to and use of appropriate STD diagnostic and treatment facilities.

In order to have a meaningful impact, STD control strategies must include the goal of increasing rates of condom use. There is clear, unequivocal evidence that the consistent use of condoms is highly effective in protecting both sexes from HIV (e.g., Saracco et al., 1993; de Vincenzi, 1994). Population level interventions, such as Thailands 100% condom policy which includes the aggressive promotion of condoms through the media, have had a profound effect on the prevalence of STDs (Hanenberg, Rojanapithayakom, Kunaso, & Sokal, 1994).

In condom use, we have a behaviour that has already been targeted in AIDS prevention campaigns. Some of these interventions have led to a demonstrated increase in condom use (for review see J.D. Fisher & Fisher, 1992; Kelly, 1995). Strategies that involve physicians and pharmacists in raising awareness of the need to use condoms even when oral contraceptives are used have also demonstrated their effectiveness (Wong-Reiger et al., 1996). The success of Switzerland's national STOP AIDS campaigns provides a strong example of the efficacy of promoting condom use. Although the Swiss program had no effect on number of sexual partners or levels of sexual activity, between 1988 and 1994 there were very substantial increases in condom use by those in the general population aged 17 to 45 (Dubois-Arber, Jeannin, Konings, & Paccaud, 1997).

In Canada, the goal of reducing STDs would be well served by maintaining and enhancing existing HIV/AIDS prevention and sexuality education programs focusing on increasing condom use and on implementing new programs where necessary. In particular, it is necessary to develop and implement group-specific programs targeted to marginalized subgroups within the Canadian population that are not being effectively reached through existing programming.

Condoms, however, are not a universally effective barrier against all STDs. The second goal is, therefore, to increase public access to and use of appropriate STD diagnostic and treatment facilities. Although prevention, rather than treatment, is the most effective means of STD control (Health Canada, 1995), the early detection and treatment of STDs can be an important tool in reducing the impact of STDs. First, early detection and treatment can reduce the incidence of STD sequelae such as cervical cancer, PID, and ectopic pregnancy. Second, the early etection and treatment of STDs can often reduce the duration of infectivity, thereby decreasing the likelihood of disease transmission to uninfected sexual partners.

The two other factors addressed in this paper, reducing number of sexual partners and age of first intercourse, do not have a direct, demonstrated efficacy as behaviour change targets in STD prevention programs. While it may be normatively desirable, for other reasons, to advocate postponement of first intercourse and a reduction in number of sexual partners, their efficacy as population-wide targets for STD prevention is not clearly supported by the available research. Mathematical modelling comparing number of sexual partners and condom use as targets for reduction of HIV transmission clearly demonstrates the superior effect of condom use on reducing new cases of HIV (Reiss & Leik, 1989). It is reasonable to expect similar effects for other STDs.

Targeting number of partners and age of first intercourse may, in some cases, be counterproductive to STD prevention. Individuals may incorrectly assume that if they delay first intercourse and have few sexual partners, they have very little risk of STD infection and thus do not need to use condoms. This type of faulty reasoning is similar to the erroneous assumption used in some HIV/AIDS education that "getting to know ones partner well" is an effective means of reducing HIV risk (see Misovich, Fisher, & Fisher, 1996). Individuals may use this advice as an excuse for high risk behaviour (Offir et al., 1993). Similarly, the false belief that delaying first intercourse and limiting the number of sexual partners is sufficient protection against STD has been shown to be associated with the avoidance of condom use (Maticka-Tyndale, 1992).

Surveillance Needs

The scarcity of data available to assess the current status of transmission-related behaviours or to provide baseline estimates against which program gains can be compared necessitates implementation of behavioural surveillance. Specifically:

• Collection of data on age, number of sexual partners (lifetime and recent), context of partnerships, age at first intercourse, condom use, socio-demographic and life circumstance characteristics and geographic region as part of STD surveillance
• Inclusion of similar questions in national surveys.

Research Needs

This review of existing research and knowledge related to social, cultural, and behavioural correlates of STDs shows a profound lack of Canadian research in this area. While we can often glean important lessons from research conducted in other countries or on related sexual health problems, the specific characteristics of the Canadian population with respect to social, cultural and behavioural factors associated with STDs make Canadian research essential to establishing appropriate targets, effective STD prevention programs and evaluations. The absence of such research impedes our ability to identify population subgroups, behaviours, social dynamics or environments that are driving the spread of STDs. Research in several areas is necessary to improve our ability to design programs, policies and strategies to reduce the incidence of STDs in Canada, specifically, research in the following area is needed:

• Identification of the specific behavioural, social, cultural and environmental factors fostering STD transmission and of specific subpopulations that are most vulnerable to sexually transmitted infections.
  
• Investigation of:
• sexual scripts and networks of sexual risk
• factors influencing conscious and unconscious risk-taking and prevention
• patterns of partnering in and across networks
• atypical and marginalized groups which are least likely to have access to existing programs and facilities.
• acceptability of alternative strategies to condom use for reduction of transmission (e.g., non-penetrative forms of sexual gratification).
  
• Development and testing of alternative methods of evaluating condom use in the face of growing normative bias toward endorsement and reporting of condom use.
  
• Evaluation of:
• program content and delivery methods targeting specific population subgroups
• availability and use of diagnostic and treatment services by different population subgroups
  
• Use of existing guidelines on patient sexual health by health care practitioners

Policy and Programs Needs

Finally, the discussions that have occurred at meetings of various working groups (i.e., Health Canada meeting, 1996) and this review of research point to several policy and program initiatives that would contribute to the reduction of STD spread:

• Development and implementation of policies and programs to foster healthy sexual practices.
• Full-scale implementation of sexual health programmes already available and evaluated
• Prioritization and support for sexual health research from the perspective of all relevant scientific disciplines.
• Encouragement of counselling, diagnosis, and treatment of sexual health problems by health care practitioners.
• Inclusion of inquiries into sexual activities as part of health screening, including national surveys, sentinel surveillance and individual counselling.
• Development of social welfare policies and partner violence and abuse programmes to decrease abusive sexual activity and reliance on sex for survival.

The Canadian data on STD rates are encouraging. We can anticipate effective elimination of some STDs and the realization of low levels of others. If we are to accomplish these goals, we must develop strategies to effect changes in sexual activities and the use and delivery of appropriate sexual health services.

Table 1-  Number of Partners in the Past Year by Age and Gender

Table 2 - Total Number of Lifetime Partners of Those with Sexual Experience

Table 3 - Number of Partners in Past Year for Those Who Participated in Sexual Intercourse

Table 4 - Age First Sexual Intercourse, Various Studies 1974-1995

Table 5 - Age of First Intercourse

Table 6 Condom Use by Age, Sex, Number and Type of Sexual Partnership

Table 7 - Condom Use With New Sexual Partner In Past Year For Three Ethnocultural Groups

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