Factors associated with the management of Sexually transmitted infections (STIs) and sexual dysfunctions (SDs): A survey of Iranian-American physicians in California
Keywords:Cultural studies, Sexuality, Iranian-American Physicians, Management of Sexual Health Care
Introduction. Knowledge on effective management strategy for sexual healthcare (i.e., sexual history taking, sexually transmitted infections, sexual dysfunctions) used by Iranian-American physicians remains a serious gap within current literature. Having this knowledge, and its impact on their patients, is essential, since discussions of sexually related topics are taboo in Iranian societies. Aim. We examined the Iranian-American physicians’ sexual healthcare management offered to their patients, within the context of the barriers, and the attitudes, inhibiting the discussion and provision of sexual healthcare. Methods. A self- administrated questionnaire was designed. 1,550 survey instruments were sent to Iranian-American physicians practicing in California. Factor analysis performed to detect relationships between correlated variables within the data. Results. 348 questionnaires (23% response rate) were returned. Four factors related to the effectiveness of sexual health care management were identified, which were internally consistent (a range of Cronbach’s alpha=0.89 to 0.94). Factors: (1) female sexual dysfunction, (2) history of sexual intercourse, (3) STI, and knowledge of disease, (4) male sexual dysfunction. Significant associations were found between variables: clinical specialty, religious affiliation, age, gender, and place of graduation. Conclusion. Results show all four factors may significantly impact the effectiveness of sexual health care management by Iranian-American physicians which can potentially influence quality of sexual healthcare for patients. Additional studies from this population and other subpopulations of US physicians are needed to design new strategies that reflect on physicians’ management on sexual healthcare delivery. If confirmed in other studies, our findings could have implications for training of medical graduates globally.
World Health Organization (WHO) http://www.who.int/reproductivehealth/topics/sexual_health/issues/en/
Accessed September 2, 2018).
Bhatia, M. S., Munjal, S. 2014. Prevalence of Depression in People Living with HIV/AIDS Undergoing ART and Factors Associated with it. Journal of Clinical and Diagnostic Research: Journal of Clinical and Diagnostic Research, 8(10): WC01– WC04. DOI.org/10.7860/JCDR/2014/7725.4927.
Nusbaum, M.R.H., Hamilton, C.D. 2002. The proactive sexual health history. Journal of American Family Physicians, 66(9):1705-1713.
Crowe, M. Couple relationship problems and sexual dysfunctions: therapeutic guidelines. Journal of Advances in Psychiatric Treatment 2012; 18:154-159. DOI: 10.1192/apt.bp.109.007443.
Laumann, E.O., Paik, A., Rosen, R.C. 1999. Sexual dysfunction in the United States: Prevalence and predictors. Journal of American Medical Association, 281(6):537-44.
Sadeghi-Nejad, H., Wasserman, M., Weidner, W., Richardson, D., Goldmeier, D. 2010. Sexually transmitted diseases and sexual function. Journal of Sex Medicine, 7(1Pt2):389- 413.
Satterwhite, C.L., Torrone, E., Meites, E., Dunne, E.F., Mahajan, R., Ocfemia, M.C., Su J, X.U.F., Weinstock H. 2013. Sexually transmitted infections among U.S. women and men: Prevalence and incidence estimates, 2008. Journal of Sexually Transmitted Diseases, 40(3): 187-193.
Centers for Disease Control and Prevention CDC (2017).
https://www.cdc.gov/nchhstp/newsroom/2016/std-surveillance-report-2015- press-release.html, (Accessed September 26, 2017).
Weigler, G., Perry, C., Weigler, A., Kim, B., Yangouyian, M., et al. 2013. Sexually Transmitted Diseases: Management by Urology, Emergency Medicine and Obstetrician/Gynecology Physicians does not Generally Follow CDC Guidelines. Journal of Community Medicine & Health Education, (3):244. DOI:10.4172/2161-0711.1000244.
St. Lawrence, J.S., Montano, D.E., Kasprzyk, D., Phillips, W.R., Armstrong, K., Leichliter, J.S. 2002. STD screening, testing, case reporting and clinical and partner notification practices: a National survey of US physicians. American Journal of Public Health, (92): 1784- 1788. DOI:10.1001/jama.294.23.2996.
Hoopes, A.J., Benson, S.K., Howard, H.B., Morrison, D.M., Ko, L.K., Shafii, T. 2017. Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study. Journal of Primacy Care and Community Health, 1-6.
Rashidian, M., Minichiello, V., Knutsen, S., Ghamsary, M. 2016. Barriers to sexual health care: A survey of Iranian-American physicians in California, USA BMC Health Services Research, 16(263). DOI 10.1186/s12913-016-1481-8.
Rashidian, M., Minichiello, V., Knutsen, S., Ghamsary, M. 2017. Effect of attitudes towards Patients on sexual history taking: A survey of Iranian-American physicians in California, USA. Journal of Sexual Health, 14(6). DOI: 10.1071/SH17016.
Centers for Disease Control and Prevention (CDC) 2018.
https://www.cdc.gov/nchhstp/newsroom/2018/press-release-2018-std-prevention- conference.html. (Accessed September 2, 2018).
Centers for Disease Control and Prevention (CDC) (2016)
https://www.cdc.gov/std/stats16/Syphilis.htm. (Accessed May 25, 2018).
Fileborn, B., Lyon,s A., Heywood, W., Minichiello, V. 2017. Talking to healthcare providers about sex in later life: Findings from a qualitative study with older Australian men and women. Australasian Journal on Ageing June. DOI: 10.1111/ajag.12450
Breskin, A., Adimora, A.A., Westreich, D. 2017. Women and HIV in the United States. PLoS ONE, 12(2): e0172367.
Nascimento, E.R., Maia, A.C., Pereira, V., Soares-Filho, G., Nardi, A.E., Silva, A.C. 2013. Sexual dysfunction and cardiovascular diseases: a systematic review of prevalence. Clinics, 68(11):1462-1468.
Thompson, I.M., Tangen, C.M., Goodman, P.J., Probstfield, J.L., Moinpour, C.M., Coltman.C.A. 2005. Erectile Dysfunction and Subsequent Cardiovascular Disease. Journal of American Medical Association, 294(23):2996-3002.
Enzin, P., Mathieu, C., Bruel, A.V. 2003. Prevalence and predictors of sexual dysfunction in Patients with type 1 diabetes. Diabetes Care, 26(2): 409-414. DOI: 10.2337/diacare.26.2.409.
Goldmeier, D.1., Leiblum, S.R. 2005. STIs and sexual dysfunction. Journal of Sexually Transmitted Infections, 81:364. DOI:10.1136/sti.2005.015727.
Goldmeier, D. 2001. Female low sexual desire and sexually transmitted infections. Journal of Sexually Transmitted Infections, 77(4): 293–294.
Clegg, M., Towner, A., Wylie, K. 2012. Should questionnaires of female sexual dysfunction be used in routine clinical practice, Maturitas, 03.009.
Bell, C., Richardson, D., Wall, M., Goldmeier, D. 2006. HIV-associated female sexual dysfunction: Clinical experience and literature review. International Journal of STD AIDS,17:706-9.
Solursh, D.S., Ernst, J.L., Lewise, R.W. 2003. The human sexuality education of physicians in North American medical schools. International Journal of Impotence Research, 15(5suppl): S41-5.
Hinchliff, S., Gott, M. 2011. Seeking medical help for sexual concerns in mid and later life: a review of the literature. Journal of Sex Research, 48:106-17.
Gott, M., Glena, E., Hinchliff, S., Elford, H.2004. “Opening a can of worms”: GP and practice nurse barriers to talking about sexual health in primary care. Journal of Family Practice, 21:528-36.
Mercer ,C.H., Fenton, K.A., Johnson, A.M. et al. 2003. Sexual function problems and help seeking behaviour in Britain: national probability sample survey. BMJ 2003;327:426–7.
Nazareth, I., King, M., Boynton, P. 2003. Problems with sexual function in people attending London general practices. BMJ, 327:423–6.
Goldmeier, D., Garvey, L.,, Barton S. 2008. Does chronic stress lead to increased rates of recurrences of genital herpes – A review of the psychoneuroimmunological evidence? International Journal of STD AIDs, 19:359-62.
Krieger, J.N., Riley, D.E. 2002. Prostatitis- what is the role of infection? International Journal of Antimicrobial Agents 2002;19:475–9.
Liang, C.Z., Zhang, X.J., Hao, Z.Y. et al. 2004. Prevalence of sexual dysfunction in Chinese men with chronic prostatitis. BJU International, 93:568–70.
Screponi, E. , Carosa, E., Di Stasi, S.M. 2001. Prevalence of chronic prostatitis in men with premature ejaculation. Urology, 58:198–202.
Duncan, B. , Hart, G., Scoular, A. et al. 2001. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis: implications for screening. BMJ, 322:195–9.
Khan, M.R., Kaufman, J.S., Pence, B.W., Gaynes, B..N, Adimora, A..A, Weir, S.S., Miller, W.C. 2009. Depression, sexually transmitted infection, and sexual risk behavior among young adults in the United States. Journal of American Medical Association, Pediatrics. Archive of Pediatrics and Adolescent Medicine, 163(7): 644–652. DOI:
Lyketsos, C.G., Hanson, A., Fishman, M, McHugh, P.R., Treisman, G.J. 1994. Screening for Psychiatric morbidity in medical outpatient clinic for HIV infection: the need for a psychiatric presence. International Journal of Psychiatry Medicine, 24:103-13.
Goldmeier, D., Johnson, A., Byrne, M. et al. 1988. Psychosocial implications of recurrent genital herpes simplex virus infection. Genitourin Med, 64:327–30.
Luby, E. D., Klinge, V. 1985. Genital herpes: A pervasive psychosocial disorder. Arch Dermatol, 121:494–497.
Kucukunal, A., Altunay, I.K., Merecan, S. 2013. Sexual Dysfunction in Men Suffering from Genital Warts. The Journal of Sexual Medicine, 10 (6). Pp 1443-1668.
El-esawy, F.M., Ahmed, H.M. 2017. Effect of Genital Warts on Female Sexual Function and Quality of Life: An Egyptian Study. Journal of Human Andrology, Article 3, 7(2).58-64. DOI: 10.21608/HA.2017.3919
Graziottin, A., Serafini, A. 2009. HPV infection in women: psychosexual impact of genital warts and intraepithelial lesions. The Journal of Sexual Medicine, 6 (3):633-45. DOI: 10.1111/j.1743-6109.2008.01151.x.
Ivanova, E.L., Hart, T.A., Wagner, A.C., Alijassem, K., Loutfy, M.R. Correlates of anxiety in women living with HIV of reproductive age. AIDS Behavior (epub), (Jan 13).
Bing, E.G., Burnam, M.A., Longshore, D. et al. 2001. Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus–Infected Adults in the United States. Arch Gen Psychiatry, 58(8):721–728. DOI:10.1001/archpsyc.58.8.721.
Gonzalez, A., Zvolensky, M..J, Parent,. ,J, Grover K.W., Hickey, M. 2012. HIV symptom distress and anxiety sensitivity in relation to panic, social anxiety, and depression symptoms among HIV-positive adults. AIDS Patient Care and STDs (epub), (Jan 16).
Kagee, A.N. 2011. Common mental health problems and antiretroviral therapy adherence, AIDS Care, (Nov 23):1360- 5. Epub 2011 (June 14).
Nussbaum, A.M. 2013. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). American Psychiatric Publishing. Arlington, VA.
Biro, F.M.,, Rosenthal S.L. 1992. Psychological sequelae of sexually transmitted diseases in adolescents. Obstet Gynecol Clin North Am, 19:209–218.
Ramrakha,. S, Caspi, A., Dickson, N., Moffit,t T.E., Paul, C. 2000. Psychiatric disorders and risky sexual behaviour in young adulthood: cross sectional study in birth cohort. BMJ, 321:263–266.
Shrier, L.A., Harris, S.K., Sternberg,. M, Beardslee, W.R. 2001. Associations of depression, self-esteem, and substance use with sexual risk among adolescents. Prev Med., 33:179–189.
Shrier, L.A., Harris, S.K., Beardslee, W.R. 2002. Temporal associations between depressive symptoms and self-reported sexually transmitted disease among adolescents. Arch Pediatr Adolesc Med., 156:599–606.
Hallfors, D.D., Waller, M,W., Bauer, D., Ford, C.A., Halpern, C.T. 2005. Which comes first in adolescence--sex and drugs or depression? Am J Prev Med., 29:163–170.
Waller,. MW., Hallfors, D.D., Halpern, C.T., Iritani,. .BJ, Ford,. CA., Guo, G.2006. Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents. Arch Womens Ment Health, 9:139–150.
Channon, S.1996. Executive dysfunction in depression: The Wisconsin card sorting test Journal of affective disorders. J Affect Discord, 39:107–114.
Rao, U. 2006. Links between depression and substance abuse in adolescents: neurobiological mechanisms. Am J Prev Med, 31:S161–S174.
Elliott, R., Sahakian, B.J., Herrod, J.J., Robbins, T.W., Paykelb, E.S. 1997. Abnormal response to negative feedback in unipolar depression: evidence for a diagnosis specific impairment. J Neurol Neurosurg Psychiatry, 63:74–82.
Elliot, R. 1998. The neuropsychological profile in unipolar depression. Trends in Cognitive Sciences, 2:447–454.
Kalichman, S.C., Kelly, J.A., Morgan. M, Rompa, D. 1997. Fatalism, current life satisfaction, and risk for HIV infection among gay and bisexual men. J Consult Clinical Psycholy, 65:542–546.
Bhatia, M. S., Munjal, S. 2014. Prevalence of Depression in People Living with HIV/AIDS Undergoing ART and Factors Associated with it. Journal of Clinical and Diagnostic Research: JCDR, 8(10): WC01–WC04.
Conaglen, H.M., Hughes, R., Conaglen, J.V., Morgan, J. 2001. A prospective study of The psychological impact on patients of first diagnosis of human papilloma virus. International journal of STD AIDS, 12:651-8.
Hatzichristou, D., Rosen, R., Broderick. G, Clayton, A., Luzin,. B, Devogatis, L, Litwin, M., Meoleman, E., O’Leary, M., Quirk, F., Sadovsky, R., Seftel, A.2004. Clinical Evaluation and management strategy for sexual dysfunction in men and women. Journal of Sex Medicine, 1:49-57.
Land, L., Nixon, S., Ross, J.D. C. 2010. Patient-derived outcome measures for HIV services in the developed world: a systematic review. International journal of STD AIDS, 21:584-90.
Berlin, E.A., Fowkes, W..C Jr. 1983. A teaching framework for cross-cultural health care. Application in family practice. West Journal of Medicine,139(6):934-8.
American Fact Finders: https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml . Visited 2013, 2016.
Rahmati-Najarkolaei, F., Niknami, S., Aminshokravi, F., Bazargan, M, Ahmadi, F., Hadjizadeh, E., Tavafian, S.S. 2010. Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran. Journal of the International AIDS Society, 13: 13-27. DOI:10.1186/1758-2652-13-27.
Rashidian, M., Hussain, R., Minichiello, V. 2013. ‘My culture haunts me no matter where I go’: Iranian-American women discussing sexual and acculturation experiences. Culture, Health Sexuality: An International Journal for Research, Intervention and Care,15(7): 866-877. DOI: 10.1080/13691058.2013.789128.
Rashidian, M., Hussain, R., Minichiello, V. 2015. Sexual Self-Concept through a Cross- Cultural Lens: Qualitative Case Studies of Iranian-American Women. Advances in Social Sciences Research Journal, 2(10). DOI:10.14738/assrj.210.1539.
Sayles, J.N., Wong, M.D., KInsler, J.J., Martins, D.M., Cunningham, W.E. 2009. The Association of Stigma with Self-Reported Access to Medical Care and Antiretroviral Therapy Adherence in Persons Living with HIV/AIDS. J Gen Intern Med., Oct; 24(10): 1101– 1108.
MacCallum, R..C, Widaman, K.F., Preacher, K.J., Hong, S. 2001. Sample size in factor analysis: the role of model error. Multivariate Behav Res, 36: 611–37. DOI:10.1207/S15327906MBR3604_06.
Comrey AL, Lee HB. A first course in factor analysis. Hillsdale, NJ: Eribaum, 1992.
Arrindell, W.A., Van-derende, J. 1985. An empirical test of the utility of the observations-to-Variables ratio in factor and components analysis. J Appl Psychol Measurement, 9: 165–78. DOI:10.1177/014662168500900205.
Fisher, T.D., Davis, C.M., Yarber, W.L., Davis, S.L. 2011. Handbook of sexuality-related measures. 3rd Edi. Routledge, NY., NY.
Polit, D.F, Beck, C.T. 2006. The content validity index: are you sure you know what’s being reported? Critique and recommendations. Res Nurs Health, 29: 489–97. DOI:10.1002/nur.20147.
Cronbach, L.J. 1951. Coefficient alpha and the internal structure of tests. Psychometrika J, 16: 297–334. DOI:10.1007/BF02310555.
Kline P. An easy guide to factor analysis. London: Routledge; 1994.
Fearn-Smith, J..D, Evans, P.H., Harding, G., Campbell J,I. 2006. Attitudes of GPs to the diagnosis and management of impaired glucose tolerance: the practitioners’ attitudes to hyperglycemia (PAtH) questionnaire. J Primary Care Diabetes, 1: 35–41. DOI:10.1016/j.pcd.2006.07.003.
Nunnaly, J. Psychometric theory. New York: McGraw-Hill; 1978.
George, D., Mallery, P. SPSS for Windows step by step: a simple guide and reference. 11.0 update (4th Ed.). Boston: Allyn & Bacon; 2003.
Khoei, E..M, Richters, J. 2008. Concepts of sexuality and health among Iranian women in Australia Australian Family Physicians, 37(3)190-192.
Hedayati-Moghaddam, M.R., Moradi, M., Mashhadi, E. 2012. knowledge and attitudes of physicians in private practice toward HIV/AIDS in Mashhad, Iran. International Journal of STD & AIDS, 23:e11-e16. DOI: 10.1258/ijsa.2009.009447.
Sakha, M.A., Kazerooni, P.A., Lari,. MA., Sayadi, M., Ebadi, F.F.A., Motazedian, N.2013. Effect of an educational intervention on knowledge, attitudes and preventive behaviors related to HIV and sexually transmitted infections in female sex workers in southern Iran: a quasi- experimental study, 24:727-735. DOI: 10.1177/0956462413482424.
Mirzaei, M., Poorolajal, J., Khazaei, S. 2013. Saatchi M. Survival rate of AIDS disease and mortality in HIV-infected patients in Hamadan, Iran: a registry-based retrospective cohort study (1997 –2011), 24 (11) 859-866. DOI: 10.1177/0956462413486457.
Tsimtsiou, Z., Konstantinos, H., Nakopoulou, E., Kyrana, E., Salpigidis, G., Hatzichristou, D. 2006. Predictors of physicians’ involvement in addressing sexual health issues. Journal of Sexual Medicine, 3: 583-588. DOI:10,1111/j,1743-6109.2006.00271.x
World Health Organization (WHO)
(http://apps.who.int/iris/bitstream/10665/258738/1/9789241512886-eng.pdf?ua=1, accessed September 20, 2017).
Burd, I.D., Nevadunsky, N., Bachmann, G. 2006. Impact of physicians’ gender on sexual history taking in a multi-specialty practice. Journal of Sex Medicine, 3:194-200. DOI: 10.1111/j.1743-6109.2005.00168.x
Bhavsar, V., Bhugra, D. 2013. Cultural factors and sexual dysfunction in clinical practice. Journal of advances in Psychiatric Treatment, 19 (2). Pp. 144-152. DOI: 10.1192/apt.bp. 111.009852.
Hoopes, A.J., Benson, S.K, Howard, H.B., Morrison, D.M., Ko, L.K., Shafii, T. 2017. Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study. Journal of Primacy Care and Community Health, 1-6. DOI: 10.1177/2150131917730210.
Rosen, R., Kountz, D. Post-Zwicker, T., Leiblum, S., Wiegel, M. 2006. Sexual Communication Skills in Residency Training: The Robert Wood Johnson Model. Journal Of Sex Medicine, 3:37-46. DOI:10.1111/j.1743-6109.2005.00135.x.
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