6.1

Sexual behaviour

National Longitudinal Survey of Youth (2011) reported that:

• 1.
  

  Obese white adolescent girls:

  
  
  
  
  • a.
    

    were more likely than nonobese girls to have a partner at least three years older;

    
    
  • b.
    

    more likely to have more than three sexual partners in 1 year; and

    
    
  • c.
    

    and less likely to use condoms during their most recent sexual encounter.

  
  
  
  
• 2.
  

  Obese girls were also at higher odds of having coital debut before the age of 13.

  
  
• 3.
  

  These differences were not present among black adolescent obese females.

The French National Survey (Contexte de la Sexualite en France 2005/06) reported that:

• 1.
  

  Obese women were 30% less likely to report having a sexual partner in the past 12 months.

  
  
• 2.
  

  Obese women were less likely to have an occasional sex partner.

  
  
• 3.
  

  However, among women with a sexual partner, there was no difference in the frequency of sexual intercourse by BMI.

  
  
• 4.
  

  Obese women were more likely to have met a sexual partner through the internet than women of normal weight.

  
  
• 5.
  

  The authors of the paper suggested that women with obesity might find it more difficult to attract a sexual partner and/or that they can establish a rapport with a potential partner while at the same time concealing their weight.

Data from the National Health and Nutrition Examination Survey from the United States:

• 1.
  

  This survey was conducted using computer-assisted self-interview.

  
  
• 2.
  

  In this survey, individuals who were overweight or with obesity reported fewer sex partners than individuals of normal weight.

  
  
• 3.
  

  18% of the male and 28% of the female respondents who reported no lifetime sex partners ever tested positive for antibodies to Herpes simplex type 2 that was used as a serological marker of sexual exposure.

6.2

Obesity and sexual function

• 1.
  

  In general, for women in the western countries, there is often a sociocultural association between slender physique and physical attractiveness.

  
  
• 2.
  

  Studies have shown that individuals perceive their obesity as a serious psychosocial handicap.

  
  
• 3.
  

  This can lead to some of the psychological manifestations of the negative body image such as low self-esteem, which could lead to difficulty in initiating a healthy sexual relationship.

  
  
• 4.
  

  In the French survey, men who were overweight or obese were more than twice as likely as normal weight men to have experienced sexual dysfunction.

  
  
• 5.
  

  With regards to sexual function among women, multivariate analysis of results found an association between obesity and lower sexual function scores.

  
  
• 6.
  

  Women with obesity may also suffer from lack of libido and reduced satisfaction with sexual life.

  
  
• 7.
  

  A self-reported Quality of Sexual Life study in the United States reported that obesity was associated with higher incidence of risky behaviour compared to normal weight.

6.3

Obesity and sexual health outcomes

• 1.
  

  Girls who are heavier will attain secondary sexual characteristics and menarche earlier than normal weight counterparts.

  
  
• 2.
  

  However, surveys from the United States showed that there was no association between age at first intercourse and BMI.

  
  
• 3.
  

  However, data from the French national survey of sexual behaviour showed that obese women who were under 30 years of age were four times more likely than women of normal weight to report an unintended pregnancy or an abortion.

  
  
• 4.
  

  The French study also showed that women with obesity were less likely to use oral contraceptive and relied on less effective methods such as “withdrawal” method.

  
  
• 5.
  

  It is possible that reliance on less effective methods may reflect difficulty in negotiating condom use with a partner, greater sexual risk-taking, or misconceptions about one’s fertility status.

  
  
• 6.
  

  It is equally possible that women with obesity are less likely to access contraceptive services (contraception hesitancy).

  
  
• 7.
  

  In another cross-sectional study of sexually active female adolescents, increased BMI was linked to higher number of sexual partners and participation in riskier sexual practices.

  
  
• 8.
  

  One US study of postpartum women reported that among women who had been using contraception at the time of conception, women with raised BMI had almost twice the rate of unintended pregnancy compared to women with normal weight.

  
  
• 9.
  

  There is limited evidence regarding the effect of obesity on the incidence of sexually transmitted infections (STI).

  
  
• 10.
  

  The French national survey of sexual behaviour among men in their late teens and 20s found that the odds of contracting an STI in the previous 5 years were more than 10 times greater for men with obesity than for men of normal weight.

  
  
• 11.
  

  However, in that survey, there was no difference between women of different BMI groups with the history of STI.

  
  
• 12.
  

  Data from the Centers for Disease Control (CDC2010) indicate that 1 in 4 young women between the ages of 14 and 19 in the United States is infected with at least one of the most common sexually transmitted diseases —human papillomavirus (HPV), Chlamydia, herpes simplex virus, and trichomoniasis.

  
  
• 13.
  

  Averett et al. hypothesised that girls who are perceived (or perceive themselves) as less attractive will be willing to incur greater risks in order to attract a partner. Boys, according to this line of thinking, would move to less physically attractive matches in order to find willing partners for risky sex.

  
  
  
  
  • a.
    

    Their findings confirm previous research indicating that overweight or obese girls are less likely to be sexually active than other girls. They also found that as a result of being less sexually active, overweight or obese girls are less likely to have vaginal intercourse without a condom.

    
    
  • b.
    

    However, overweight or obese girls are not less likely to have sex under the influence of alcohol, and once they have had vaginal intercourse, their consistency of condom use is no different from that of their recommended-weight peers.

    
    
  • c.
    

    However the most striking finding was that overweight or obese girls were at least 15% more likely than their recommended-weight peers to have had anal intercourse.

  
  
  
  
• 14.
  

  Kershaw et al. examined the effect of BMI groups (normal weight, overweight, and obese) at 6 months postpartum on STI incidence and risky sex (e.g., unprotected sex, multiple partners, risky and casual partner) at 12 months postpartum.

  
  
  
  
  • a.
    

    At 6 months postpartum, 31% of participants were overweight and 40% were obese.

    
    
  • b.
    

    Overweight women were more likely to have an STI (OR=1.79, 95% CI=1.11–2.89, P < .05) and a risky partner (OR=1.64, 95% CI=1.01–2.08, P < .05) at 12 months postpartum compared to normal weight women.

    
    
  • c.
    

    However, obese women were less likely to have an STI than normal weight women (OR=0.57, 95% CI=0.34–0.96, P < .01).

  
  

6.4

Managing sexuality issues of young obese women

• •
  

  Provide a more holistic approach with greater focus on developing positive attitudes and values towards sex, sexuality and relationships.

  
  
• •
  

  This in turn can help to develop the knowledge and behaviour necessary to reduce harm at both personal and societal level, as part of wider health and wellbeing education.

  
  
• •
  

  Some field work in this area suggests that young people regard school as their primary and preferred source of information about sex.

  
  
• •
  

  The school delivery system provides the opportunity to develop a tailored program, delivered at age-appropriate intervals, and with scope to build on previous learning over a number of years.

  
  
• •
  

  Ideally, this should commence in early years and have clear parameters, developed in conjunction with parents and other stakeholders.

  
  
• •
  

  School-based delivery provides scope for regulation and consistency, and has been shown to be a cost-effective approach.

  
  
• •
  

  Structured sex education programs should be focused on increasing knowledge about sexual and reproductive health-related issues, prevention of sexually transmitted infection, and condom use.

  
  
• •
  

  Sexuality education should focus on the key components:

  
  
  
  
  • •
    

    Correct use of different methods of contraception especially around use of condoms, both male and female.

    
    
  • •
    

    The availability of postcoital contraception.

    
    
  • •
    

    The use of various methods of contraception and from where to access them.

    
    
  • •
    

    The effectiveness of long acting reversible hormonal methods of contraception.

    
    
  • •
    

    The risks of acquiring STI following unprotected intercourse with a new partner.

    
    
  • •
    

    Should be advised that using a condom during intercourse helps to prevent STI.

    
    
  • •
    

    Contact tracing and treatment is warranted for the male partner as well.

    
    
  • •
    

    And be aware of signs and symptoms of common STIs for which they should be seeking investigations and treatment ( Table 6.1 ).

    
    
    
    

    Table 6.1

    
    

    Common sexually transmitted infections.

    
    

    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    

    Infection	Signs/symptoms	Examination	Investigation	Treatment	Long-term effects
    Chlamydia, (caused by bacterium Chlamydia trachomatis )	Mostly asymptomatic, vaginal discharge (30%), postcoital/intermenstrual spotting, burning feeling on passing urine (Urethritis or cystitis), pelvic inflammatory (PID) disease (10%–30%) as pelvic pain/lower abdominal pain, anal discharge, discomfort, pruritus (anal coitus)	Tenderness in both adnexa at vaginal examination, cervical excitation/contact bleeding, Cervix shows hyperaemia and oedema	– Endocervical swab for ELISA, – MSSU, Self Vaginal swab, – Pharyngeal swabs (oral sex risk), – Rectal swab (risk of anal intercourse)	– Doxycycline 100 mg BD for 1 week, – Azithromycin 1 g single dose, – During pregnancy, Erythromycin 500 mg QID for 1 week	– increased risk of infertility (tubal), – Ectopic pregnancy, – Pelvic inflammatory disease, Chronic pelvic pain, – transmission to partner, During pregnancy- transmission to newborn
    Gonorrhoea, Caused by Gram-negative diplococci Neisseria gonorrhoeae	May present as asymptomatic, acute PID (lower abdominal or pelvic pain), dysuria without increased frequency, abscess of Bartholin gland, mucopurulent discharge, intermenstrual spotting/bleeding after intercourse, anal discharge/anal or perianal pain	vaginal examination, cervical excitation/contact bleeding from the Cervix, muco-purulent cervical discharge	Endocervical swab, – MSSU, – Self vaginal swab	– Ceftriaxone 1 g I/M as a single dose. – ciprofloxacin 500 mg or ofloxacin 400 mg (not to be used during pregnancy), Azithromycin 2 g as a single dose, – Acute PID: local protocol (add Co-amoxiclav/erythromycin)	PID (follow local protocols), increased risk of infertility (tubal), – Ectopic pregnancy, – transmission during pregnancy- transmission to newborn
    Genital Herpes – Herpes simplex-type1. 2-Herpes simplex type2	Type 1: Oro-genital lesion Type 2: genital herpes, recurrence quite common	Could be asymptomatic, or present with painful blisters, leading to ulceration associated with dysuria, painful anogenital discharge, systemic symptoms in primary infection	– HSV detection by PCR, – NAAT Test, – HSV specific antibodies	– Simple analgesics, – Saline bathing, – Topical anaesthetic such as 5% lidocaine gel, – Anti-viral drugs within 5 days of starting of the episode, (Aciclovir 400 mgX3 daily, Valaciclovir 500 mgX 2 daily) – Managing urinary symptoms which may require catheterisation, – local protocols for recurrent infections	– Regular and correct use of condom, – Suppressive therapy, – Super infections, usually with candida and streptococcus, – Autonomic neuropathy causing urinary retention, – Autoinoculation to fingers and adjacent skin, – asymptomatic meningitis
    Bacterial Vaginosis (BV) caused by anaerobic bacteria: Gardnerella vaginalis , Atopobium vaginalis , and some other bacteria	– Not an STI but associated with sexual activity, – Vaginal pH >4.5, – Common cause of vaginal discharge with a “fishy odour,” – Pain, itch or burn in the vagina, –burning sensation when urinating and -itching around introitus – Associated with using vaginal deodorants, smoking and vaginal douches, – A recent change in sexual partner, – And in the presence of an STI.	– A thin watery, clear, or sometimes grey/greenish coloured discharge, – It coats vaginal wall, Not usually associated with signs of inflammation	Two Criteria: Amsel’s Criteria : at least 3 out of 4 are present, – Thin white homogenous vaginal discharge, – Clue cells on wet microscopy, – Vaginal pH>4.5, – Whiff of fishy odour. Hay/Ison Criteria: Grade 3 (BV)- predominantly Gardnerella and/or Mobiluncus morphotypes. Few or absent Lactobacilli, – DNA-Probe based lab tests	– Metronidazole 400 mg orally X twice for 7 days, – Metronidazole 2 g oral single dose, – Intravaginal MetronidazoleGel (0.75%) daily for 5 days, – Intravaginal Clindamycin cream 2% daily for 7 days, – Tinidazole 2 g single oral dose, – Clindamycin 300 mg oral X twice for 7 days	– Females with BV are at increased risk of acquiring STI, – probably implicated in aetiology of STI, – HIV positive women with BV have an increased risk of transmitting HIV, – recurrent infection at 12 months following treatment, – associated with new partner, – Recurrent BV treatment is challenging and requires longer courses of treatment following consultation with Genitourinary Medicine specialist
    Vulvovaginal candidiasis (caused by yeasts of genus Candida )— VVC	– Normal flora of female genital tract, – Over 20 candida species that can infect humans, – C. albicans is commonest (80%–90%), – around 75% will have at least one lifetime episode of VVC, – 40%–45% will have at least two or more episodes, – Risk of recurrent VVC is 10%–25%	– Vulval itch, – Nonoffensive vaginal discharge, – soreness or burning feeling, – Superficial dyspareunia, – Cyclical symptoms, – On examination of skin: – Erythema, fissuring, swelling/oedema, Satellite lesions and excoriation marks. – Nonoffensive and cottage cheese like vaginal discharge, – discharge may be thin or even absent,	– clinical picture, – High vaginal swab of the discharge, – Culture recommended only in recurrent VVC, Reassure that it is not sexually transmitted.	– Avoid local irritants, – soap substitute (emollients), – rule out iron deficiency, – Fluconazole capsule 150 mg- single dose, – Clotrimazole pessary 500 mg vaginally, – Itraconazole 200 mg oral X twice for one day, – recurrent or severe VVC will require long courses of treatment	Increased risks with: – Diabetes, – Steroid treatment, – Immunosuppression, – Pregnancy, – HRT, – Combined oral contraceptive, – Recurrent antibiotics treatment, – Persistence of Candida, – Significant effect on quality of life
    Trichomonas Vaginalis (TV): TV is a protozoon	– Found in Urethra in 90% of women infected, and also in vagina and para urethral glands, – Transmitted through sexual intercourse	– Up to 50% may be asymptomatic, – frothy vaginal discharge, – Vulval itching, – Dysuria, – offensive odour, – Occasionally lower abdominal pain or Vulval ulceration. – Vulvitis and vaginitis, – strawberry cervix,	– Vaginal swab from posterior fornix, – Self –obtained Vaginal swab, – Urine	– Metronidazole 2 g oral single treatment, – Metronidazole 400 mg BDX 7 days, Tinidazole 2 g oral single dose – Avoid intercourse for one week after completion of treatment,	– May be associate with negative impact on pregnancy, – may enhance HIV transmission,
    Anogenital Warts, caused by Human papilloma Virus (HPV)- DNA Virus	– More than 100 genotypes, – 90% caused by HPV types 6 or 11, – Most infections resolve spontaneously, – Median incubation period is 3 months, – High risk HPV found in cervical squamous cell carcinoma are type 16, – Usually transmitted by sexual contact,	– Benign epithelial skin lesions, – Singe/multiple, – “Cauliflower”-like on moist nonhair bearing areas, – “smooth papules” on dry hair skin, – May occur at any genital or perigenital site, – Extra genital lesions can occur in oral cavity, larynx, conjunctiva and nasal cavity. – mostly asymptomatic, – can also cause local irritation, bleeding, discomfort, secondary infection and local tissue infiltration	– Classical appearance, – rarely biopsy is required, – colposcopy, – suspicious lesions require biopsy to rule out anogenital intra-epithelial neoplasia	Nonkeratinised lesions: – Podophyllotoxin, – Trichloroacetic acid, – Imiquimod. Keratinised Lesions: – Cryotherapy, – Excision, – Elecrotcautery, – Imiquimod, Other options: – 5 Fluorouracil 5% Cream, – Interferons, – Cidofovir 1% cream, – Laser therapy	Prevention of Warts: HPV Vaccination, – Bivalent (HPV 16, 18), Quadrivalent (HPV 16, 18, 1, 16)
    Syphilis, caused by Treponema Pallidum	– Transmitted by direct contact with an infectious lesion, mainly via genital route, – vertical transmission during pregnancy, – route of transmission is extra-genital in homosexual sex,	– Congenital (Early in first 2 y, and late- after 2 y), – Early syphilis (Primary, Secondary, Early latent), – Late syphilis (Late latent, and Tertiary). Primary syphilis: – Chancre (ulcer)—superficial, single, painless and clean base, – Can be atypical as being multiple, painful and diffuse, – Untreated chancres resolve spontaneously 3–8 weeks later,	Primary: Serum from chancre, – Aspiration of regional lymph nodes if chancre is infected – Secondary and early congenital syphilis : – Serum from mucosal patches and ulcers, – PCR, – Positive serology around 4 weeks of infection, – VDRL Carbon antigen test/RPR test, – Specific treponemal tests for IgG and IgM, – Anti- treponemal IgM EIA and immunoblot, – Treponemal EIA/CLIA or TPPA, – Rapid treponemal tests, – All these tests have false positive and negatives, – All positive tests should be re-tested	– Offer full sexual screen, – No sexual contact till lesions of early syphilis are treated, – Longer duration of treatment in late syphilis as the bacteria divide slowly, – Parenteral rather than oral treatment, – Macrolide antibiotics: Choices: – Benzathine penicillin, – Doxycycline, – Azithromycin, – Procaine Penicillin, – Ceftriaxone, – Amoxicillin, – Erythromycin	Secondary Syphilis: – Multi system bacteraemia, – widespread rash, – mucus patches, – Condylomata lata, – Periostitis, – Liver, spleen, renal eye, CNS involvement, – Latent Disease (Tertiary) – Gummatous disease, – cardiovascular, – Late neurological disease, Useful websites are: https://iusti.org/regions/guidelines https://www.bashh.org/guidelines https://www.bhiva.org/guidelines
    Molluscum contangiosum (caused by this DNA virus)	– Benign epidermal eruption of skin, – Four subtypes, with MCV 1 is the commonest, – Routine physical contact or occasionally fomites, – Lesions usually affect face and neck, trunks or limbs, – As STI: – Affects young adults, – Usually affects genitals, pubic region, lower abdomen, upper thighs, buttocks, – Severe infection in : – Immunocompromised, – Late stage HIV,	– Incubation (2–12 weeks), – Smooth surfaced, firm, doom shaped papules, – Usually asymptomatic, – White colour, but can be pink to yellow, – Can get infected, – Appear as clusters, – Rarely affect oral cavity or sole of foot, – Can be widespread in immunocompromised.	Clinical diagnosis, – Rarely biopsy may be required with atypical presentation	– General advice, – Risk of autoinoculation, – Not to shave/wax genital area, – Not to squeeze the lesion as the central plug is full of infectious material, – Expectant treatment, – Podophyllotoxin 0.5% for genital lesions, – Liquid nitrogen, – Curettage for nonfacial nongenital lesions	Differential diagnosis: # – basal cell carcinoma, – cysts, – abscesses, – genital warts, – Keratoacanthoma, – fungal infection
    Mycoplasma genitalium	– Self-replicating bacterium, – Lacks a cell wall, not visible by Gram stains, – Infection may persist for months or longer	Majority do not develop a disease, – Transmission is genital-genital/penile-anal contact, – Responsible for nongonococcal urethritis (dysuria), – Can cause post coital bleeding, uterine infection and PID, – painful intermenstrual bleeding	– Vulvo-vaginal swabs, – Endocervical swab, – First void urine sample, – NAATs detects M. genitalium specific DNA/RNA in clinical specimen	– Macrolide antibiotics, – Doxycycline, – Azithromycin, – Moxifloxacin, Patient advice: – Abstain from sexual intercourse for 14 days after start of treatment, – Attend for test of cure, – Partner treatment	Nongonococcal/nonchlamydial urethritis, – Pelvic inflammatory disease, – Muco-purulent cervicitis, – Sexually acquired proctitis, – Effect on fertility (lack of good evidence)

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