Association of sexual perceptions, behavior, and intimate partner violence with sexually transmitted infection (STI) among Filipino women

TL;DR

This study explores how sexual perceptions, behaviors, and intimate partner violence relate to STI risk among Filipino women using national survey data.

Contribution

The study identifies novel associations between intimate partner violence and STI risk in Filipino women using nationally representative data.

Findings

Reproductive coercion nearly doubles STI risk in Filipino women.

Perceiving domestic abuse as justified increases STI risk by 12%.

Emotional violence and fear of partners are strongly linked to higher STI rates.

Abstract

Sexually transmitted infections (STI) remain prevalent in the Philippines despite being both preventable and treatable. Women are particularly vulnerable when less prioritized than high-risk groups and unable to speak up in abusive intimate relationships. Although studies on behavior and STI have been conducted, they vary by culture and region, highlighting the importance of representative studies. This study aimed to identify sexual perceptions and practices, and intimate partner dynamics associated with STI in Filipino women.

A secondary analysis of the 2022 Philippine Demographic Health Survey was conducted: 19,228 sexually active women in relationships, weighted by region. The outcome: a composite of self-reported STI and related symptoms in the last 12 months. Variables tested: sociodemographic factors, safe sex practices, and perceptions, such as the ability to refuse sex and ask a partner to wear a condom, justifying partner violence, and intimate partner coercion and abuse. Descriptive statistics and modified Poisson regression analysis were conducted to identify significant factors and estimate their risk ratios; the p-value (p) was set at < 0.05.

One thousand three hundred thirty-nine females reported having an STI (6.96% [CI: 6.19%, 7.73%]). Reproductive coercion nearly doubled the risk of STI. Women who perceived domestic abuse to be justified increased their risk of STI by 12%. Emotional violence and fear of one’s partner consistently increased the risk for STI (ARR: 1.29 and 1.33, respectively). Physical and sexual abuse were also associated with STI.

Routine STI testing of IPV victims is recommended as well as expanding STI risk assessment to sexual perceptions and history of IPV. STI surveillance is incomplete when focused on high-risk groups only. Human rights-based approach on sexual practices, and gender equality should be values instilled in mandatory pre-marriage family planning seminars and sex education, grounded on mutual respect, and consent. Without correcting harmful perceptions on domestic abuse and IPV prevention, STI control may not be completely achieved.

Full text

Introduction

The World Health Organization estimates over a million preventable STI cases daily among adults 15–49 years old [1]. In 2021, the prevalence of non-HIV STI among Southeast Asian women (22.68%) was higher than the overall regional average; Filipino women experience higher prevalence and incidence rates than the national figures, with no decline observed in the past five years [2]. STI disproportionately affect women younger than 25 years old, from low to middle-income countries (LMICs) [3].

Condom use and the number of sexual partners are known to influence STI prevalence. However, various underlying factors also shape these behaviors. Without accounting for them, infection control can be undermined. Individual factors such as substance and alcohol use can increase risky sex behavior [4–6]. In intimate relationships, communicating expectations of safe sex practices can protect women from potential STI risk through self-assertion [7–9]. In culturally conservative societies, education on safe sex practices and STI is often absent in classrooms when abstinence is promoted as the sole approach [6, 10, 11]. Intimate partner violence (IPV) is strongly linked to STI, particularly in young women with lower levels of education [12]. Coercive, unequal relationship dynamics and threatening environments contribute to women’s susceptibility to the infection [13]. However, social determinants differ depending on ethnicity and region: in Africa, higher education and wealth indices increased the odds of STI, while opposite findings were seen among American women [7, 14, 15]. This emphasizes the importance of representative studies to guide surveillance, prevention, and counseling programs.

STI surveillance in developing countries focuses on high-risk populations: female sex workers (FSW) and males having sex with males (MSM) [16–18]. Non-HIV STI and the general female population tend to be overlooked, leading to gaps in understanding the burden of infection. In the Philippines, traditional roles prevail where men are less likely to participate in reproductive health initiatives, believing it is beneath them as heads of households [19]. This puts female partners at risk of STI and other diseases. Hostility and altercations between couples were reported when condom use was brought up by the health centers [19].

To the best of our knowledge, this is the first study investigating sexual perceptions, practices, and domestic violence in women with STI using the 2022 P-DHS. Despite limitations of self-reporting, a nationally representative sample can shed light on STI susceptibility among women. The study aimed to determine the characteristics of sexually active Filipino women associated with having an STI: their sexual perceptions, behavior, and intimate partner dynamics, and to identify potential risk factors.

Methodology

Philippine demographic health survey

The dataset is available online upon request at the DHS website1. The Institutional Review Board of the Intercity Fund (ICF) reviewed and approved the study protocol; the Philippine Statistics Authority approved data collection and public use of datasets, assured anonymity, and secured consent of respondents [20]. The P-DHS employed a two-stage stratified sample design, utilizing 1247 primary sampling units drawn from a master sample frame (systematically selected from 33 highly urbanized cities and 42036 barangays). From these primary sampling units, 22 or 29 sampling housing units were randomly selected. In each housing unit, no more than three households were interviewed per housing unit [21]. Responses were taken from the Women’s Questionnaire. From these responses, women were selected to answer the Domestic Violence Module. This study conducted a secondary analysis using data from the 2022 P-DHS.

Selection of study population

The primary inclusion criteria were female respondents 15–49 years old who had been sexually active and responded ‘yes’ or ‘no’ to having experienced an STI or related symptoms (genital ulcers and abnormal vaginal discharge) in the past year. The sample size was limited by the availability of responses for domestic violence and sexual autonomy. Respondents were either married or living with a partner. The final study sample size was 12178 females. The applied weights of the subsample were adjusted to the original dataset to conserve the sampling validity of the DHS with accurate regional representation.

The outcome is a composite of three variables: having an STI, presence of a genital ulcer, and abnormal genital discharge [22]. All occurrences were self-reported in the last 12 months from when the interview was conducted in May-June 2022.

Investigated variables

Sociodemographic variables were included: age, urban vs. rural residence, highest educational level attained, wealth index categorized, occupation categorized, and religion. Frequency of alcohol consumption, and sexual history such as: age at first sexual contact, recent sexual activity, number of lifetime partners, and condom use were also investigated. Sexual autonomy was characterized by the ability to refuse sex, ask a partner to wear a condom, and a history of reproductive coercion. For IPV, having a controlling partner and a history of emotional, physical, and sexual abuse were included. Appendix A shows a description and a complete list of the variables included. The person deciding on the respondent’s healthcare, purchases, and family visits was also investigated: the respondent alone, their partner, relative, or others.

The respondent’s perception of domestic abuse justification (termed “wife beating justification” in the DHS) was characterized by a score based on five questions. Is a husband justified in beating his wife if: 1) she goes out without telling her husband, 2) neglects her children, 3) argues with her husband, 4) refuses to have sex with her husband, or 5) burns the food? Two points were given for ‘yes’ or in agreement, one for ‘I don’t know’ or uncertain, and zero for ‘no’ or disagreement. A higher score indicates that the respondent believes that physical domestic violence of a wife by her husband is justified in most of the given scenarios [23].

Statistical methods used

Data analysis was conducted in R version 4.4.1. Descriptive statistics, Pearson’s chi-square test, Kruskal-Wallis test, and univariate modified Poisson regression analysis were performed to determine significant associations between variables and STI. A significant p-value of < 0.05 was used.

In building the multivariate regression model, variables were selected primarily based on literature and theoretical relevance [23–25]. For the modified Poisson regression analysis [26], p-values from a Wald-type hypothesis testing and link test for model misspecification were used, as well as the weighted area under the receiver operating curve (AUC-ROC), to guide model building. Wald-type hypothesis testing assessed the significance of the coefficients versus a zero coefficient. A p-value < 0.05 meant the null hypothesis could be rejected, and the combination of coefficients improved model fit [27]. The link test for generalized linear models was used to check for violated assumptions given a group of variables [28]. The weighted AUC-ROC measured the discriminative power of the model. The model estimated crude and adjusted risk ratios, along with their 95% confidence intervals. Multicollinearity was checked using the variance inflation factor (VIF). Variables with VIFs less than 5 were included.

Results

Out of 12,178 respondents (unweighted count), STI prevalence among Filipino females was 6.96% (CI: 6.19%, 7.73%), with a weighted frequency of 1339. The total weighted count was 19,228. All answered the domestic violence module: currently married, cohabiting or separated from their husbands, or non-marital cohabiting unions.

Table 1 shows a cross-tabulation between sexual practices and perceptions, domestic violence experiences, and their STI outcome. P-values were from the Pearson’s chi-square test. Among the sociodemographic factors, only residence type was significantly associated with STI: more rural than urban cases. Women 20–24 years old had the greatest proportion of STI (10.11%). The proportion of STI cases was greater among those who experienced reproductive coercion (14.86%) versus those who had not experienced it (6.59%). Various types of domestic violence were significantly linked to STI: emotional, physical, and sexual. Fear of their current partner and abuse from a previous partner were also associated with an STI. Respondents’ ability to refuse sex, ask a partner to wear a condom, and recent condom use were notably not associated with STI in this population.

Table 1. Prevalence of STI by sociodemographic characteristic, sexual perceptions, practices, and intimate partner violenceVariableSTINoYesWeighted FrequencyP-valueAge in categories0.128 15–1991.09%8.91%378 20–2489.89%10.11%1633 25–2992.46%7.54%2926 30–3493.11%6.89%3702 35–3994.50%5.50%3598 40–4492.86%7.14%3707 45–4993.85%6.15%3284Residence type 0.025  Urban93.95%6.05%10,424 Rural91.96%8.04%8804Highest education level attained0.657 None93.66%6.34%161 Primary93.56%6.44%2646 Secondary92.61%7.39%9510 Tertiary93.42%6.58%6910Wealth index categorized0.655 Poorest92.68%7.32%3846 Poorer92.12%7.88%3854 Middle93.20%6.80%4024 Richer93.86%6.14%3876 Richest93.34%6.66%3629Occupation categories0.122 Unemployed93.31%6.69%7881 Professional/technical/managerial93.54%6.46%2525 Clerical95.12%4.88%917 Sales91.04%8.96%3422 Agricultural- self-employed92.20%7.80%936 Services92.54%7.46%940 Skilled manual92.42%7.58%594 Unskilled manual94.56%5.44%1930 Don’t know95.47%4.53%85Religion0.484 Roman Catholic92.85%7.15%14,564 Protestant93.34%6.66%1858 Iglesia ni Cristo94.56%5.44%502 Aglipay91.55%8.45%287 Islam94.80%5.20%1358 Other Christian93.82%6.18%453 No religion93.05%6.95%20 Other88.41%11.59%187Recent sexual activity 0.015  In the last 4 weeks92.64%7.36%14,227 More than 4 weeks, postpartum90.03%9.97%651 More than 4 weeks, non-postpartum94.79%5.21%4350Wife is justified to ask husband with STI to wear a condom ^a^0.247 No93.31%6.69%3473 Yes93.08%6.92%15,294 I don’t know89.73%10.27%461Not having sex because husband has other women0.924 No92.69%7.31%2036 Yes93.08%6.92%16,984 I don’t know92.85%7.15%208Can Refuse Sex0.082 No94.28%5.72%1434 Yes92.89%7.11%17,595 I don’t know97.46%2.54%199Can Ask Partner to Wear a Condom0.115 No92.35%7.65%3782 Yes93.08%6.92%14,716 I don’t know95.79%4.21%731Reproductive Coercion < 0.001  No93.41%6.59%18,372 Yes85.14%14.86%856Living with Partner0.104 Yes93.21%6.79%17,892 No90.71%9.29%1336Union status0.755 Married92.96%7.04%12,669 Cohabitation93.19%6.81%6559Condom used during last sex with most recent partner0.311 No92.91%7.09%17,812 Yes93.38%6.62%425 No Answer95.26%4.74%991Emotional violence ^a^ < 0.001  No93.76%6.24%16,386 Yes88.91%11.09%2842Physical violence- less severe ^a^ 0.029  No93.21%6.79%18,072 Yes90.29%9.71%1156Physical violence- more severe ^a^ 0.004  No93.19%6.81%18,750 Yes87.25%12.75%478Sexual violence ^a^ < 0.001  No93.26%6.74%18,835 Yes82.48%17.52%393Injuries from partner ^a^ 0.028  No93.17%6.83%18,636 Yes88.93%11.07%592Hurt partner unprovoked 0.008  No93.30%6.70%17,785 Yes89.85%10.15%1443Partner consumes alcohol0.667 No93.23%6.77%8788 Yes92.88%7.12%10,440Respondent’s father ever beat mother 0.021  No93.35%6.65%16,213 Yes91.03%8.97%2698 I don’t know94.17%5.83%317Coerced to perform unwanted sexual acts 0.016  No93.13%6.87%18,929 Yes86.10%13.90%274 Prefer not to answer96.94%3.06%25 Afraid of husband/partner < 0.001  Never93.64%6.36%15,760 Most of the time84.36%15.64%220 Sometimes90.69%9.31%3247Previous husband/partner abused respondent 0.001  Never92.38%7.62%12,318 < 1 year ago98.73%1.27%39 > 1 year ago89.86%10.14%313 Don’t remember when88.75%11.25%454 Never had another partner94.81%5.19%6104 No93.37%6.63%11,441 Yes92.54%7.46%7787Person deciding respondent’s health care 0.009  Respondent alone93.24%6.76%8902 Respondent and partner92.88%7.12%9332 Husband/partner alone93.00%7.00%985 Someone else100.00%0.00%7 Other0.00%100.00%4Person deciding respondent’s big purchases 0.025  Respondent alone91.68%8.32%4068 Respondent and partner93.69%6.31%12,830 Husband/partner alone92.05%7.95%2278 Someone else79.22%20.78%33 Other87.57%12.43%18Person deciding respondent’s visits to family or relatives 0.003  Respondent alone92.06%7.94%4067 Respondent and husband/partner93.49%6.51%13,676 Husband/partner alone91.91%8.09%1473 Someone else49.63%50.37%12Number of sex partners, excluding spouse, in last 12 months"0.186 093.05%6.95%19,135 191.54%8.46%92 222.07%77.93%1P-values in bold indicate statistically significant results (*p < *0.05).^a^Refer to Appendix A for full description of the variable

Table 2 presents the mean, median, and p-values for STI with continuous variables. Most variables are positively skewed. The median and interquartile range (IQR) were used since the data was not normally distributed; however, the difference in central tendency could not be observed with these alone, hence the mean and standard deviation (SD) were also included. Women with STI had partners with more controlling issues compared to non-infected women (p-value < 0.001). For a list of controlling issues, refer to Appendix A. The number of sexual partners in their lifetime, age at first sexual contact, number of non-spousal sexual partners, and frequency of alcohol consumption were not associated with STI in this population.

Table 2. Descriptive statistics of continuous variables for women with and without STIRangeWithout STIWith STI Weighted Mean

SD

Weighted Median

IQR Weighted MeanSDWeighted MedianIQRp-valueJustified domestic violence score ^a^0–100.280.97000.491.42000.105Age at first sexual contact8–4620.193.9519420.024.141950.219Number of controlling issues with partner ^a^0–50.591.02010.871.2601 < 0.001 Days in a month consuming alcohol0–300.351.58000.482.35000.618Number of sexual partners in the last year0–20.000.07000.010.09000.688Total lifetime sexual partners1–201.463.58101.422.53100.934P-values in boldindicate statistically significant results (p < 0.05).^a^Refer to Appendix A for full description of the variable

Table 3 shows the crude and adjusted estimated risk ratios from a modified Poisson regression analysis. Results shown are from one model only, so risk ratios of domestic violence variables are adjusted for sociodemographic factors and sexual perceptions and practices. P-values shown are for the adjusted risk ratios. Women who were 30–49 years old had a lower risk of STI compared to 20–24-year-olds. Muslims had lower STI risk compared to Catholics (ARR: 0.60, [CI: 0.38, 0.95]); this was the only significant finding among religion types. Consistent with bivariate analysis, reproductive coercion increased STI risk by 85%. Women who perceived domestic abuse to be justified had an increased risk of STI: a one-point increase in the score led to a 12% increase in STI risk. Emotional violence and fear of their partner consistently increased the risk for STI (ARR: 1.29 and 1.33, respectively).

Table 3. Risk ratios of STI by sexual factors and IPV in Filipino womenCRR95%CIARR95%CIp-valueAge in Categories15–190.88[0.40,1.92]0.87[0.42,1.81]0.71620–24REFREF25–290.75[0.49,1.13]0.73[0.50,1.08]0.11530–340.68[0.48,0.97]0.61[0.43,0.86]0.00535–390.54[0.39,0.76]0.49[0.35,0.68]< 0.00140–440.71[0.50,1.00]0.65[0.45,0.94]0.02345–490.61[0.39,0.94]0.57[0.36,0.91]0.019Residence TypeUrbanREFREFRural1.33[1.03, 1,71]1.25[0.97,1.61]0.078.Education levelNoneREFREFPrimary1.02[0.34,3.05]0.79[0.27,2.30]0.667Secondary1.17[0.39,3.48]0.92[0.31,2.73]0.882Tertiary1.04[0.35,3.11]0.85[0.27,2.70]0.788Wealth indexPoorestREFREFPoorer1.08[0.84,1.38]1.04[0.80,1.35]0.792Middle0.93[0.67,1.29]0.95[0.70,1.30]0.770Richer0.84[0.60,1.18]0.92[0.58,1.43]0.698Richest0.91[0.63,1.31]1.03[0.68,1.55]0.889Occupation categoriesUnemployedREFREFProfessional/technical/managerial0.97[0.72,1.29]1.00[0.73,1.37]0.996Clerical0.73[0.47,1.14]0.78[0.49,1.24]0.285Sales1.34[0.99,1.81]1.32[0.97,1.78]0.074.Agricultural- self-employed1.17[0.83,1.63]1.13[0.80,1.60]0.483Services1.11[0.71,1.75]1.06[0.69,1.64]0.786Skilled manual1.13[0.66,1.94]1.13[0.65,1.95]0.674Unskilled manual0.81[0.59,1.12]0.82[0.60,1.10]0.187Don’t know0.68[0.26,1.79]0.60[0.22,1.63]0.316ReligionRoman CatholicREFREFProtestant0.93[0.67,1.29]0.85[0.63,1.14]0.285Iglesia ni Cristo0.76[0.38,1.53]0.72[0.35,1.50]0.384Aglipay1.18[0.68,2.06]1.06[0.63,1.79]0.824Islam0.73[0.48,1.10]0.60[0.38,0.95]0.029Other Christian0.86[0.46,1.61]0.94[0.51,1.71]0.830No religion0.97[0.20,4.80]1.60[0.33,7.80]0.561Other1.62[0.83,3.15]1.44[0.71,2.92]0.313Days consumed alcohol monthly ^b^1.03[0.99, 1.07]1.02[0.98,1.06]0.380Age at first sexual contact ^b^0.99[0.96, 1.02]1.02[0.99,1.05]0.295Current marital statusMarriedREFREFUnmarried, living with a partner0.97[0.79, 1.19]0.70[0.55,0.88]0.002Residing with partnerYesREFREFNo1.37[0.94, 1.99]1.62[1.10,2.36]0.013*Recent sexual activityIn the last 4 weeksREFREFMore than 4 weeks, postpartum1.35[0.85,2.15]1.32[0.87,1.99]0.186More than 4 weeks, non-postpartum0.71[0.53,0.94]0.66[0.49,0.90]0.010Justified to ask partner with STI to wear a condomNoREFREFYes1.03[0.80,1.33]1.12[0.86,1.45]0.407I don’t know1.53[0.98,2.39]1.72[1.11,2.66]0.014Number of sex partners, excluding spouse, in last 12 months0REFREF11.22[0.35, 4.24]1.01[0.30,3.42]0.982211.21[6.01, 20.91]2.89[1.19,6.99]0.019Total lifetime sexual partners ^b^1.00[0.98, 1.01]0.99[0.97,1.01]0.343Not having sex because husband has other womenNoREFREFYes0.95[0.70,1.27]0.93[0.67,1.30]0.682I don’t know0.98[0.41,2.30]0.86[0.41,1.81]0.692Respondent can refuse sexNoREFREFYes1.24[0.89,1.74]1.45[1.00,2.12]0.051.I don’t know0.44[0.15,1.34]0.70[0.21,2.36]0.561Respondent can ask partner to use a condomNoREFREFYes0.90[0.74,1.11]0.93[0.76,1.14]0.475I don’t know0.55[0.31,0.99]0.58[0.31,1.11]0.100Condom used during last sex with most recent partnerNoREFREFYes0.93[0.47,1.85]0.98[0.49,1.96]0.949No response0.67[0.40,1.12]0.60[0.35,1.03]0.062.Justified domestic violence score ^a, b^1.14[1.06, 1.23]1.12[1.04,1.21]0.004Reproductive coercionNoREFREFYes2.25[1.64, 3.09]1.85[1.37,2.49]< 0.001Number of controlling issues from partner ^a, b^1.22[1.13, 1.31]1.07[0.98,1.18]0.129Emotional violence ^a^NoREFREFYes1.78[1.44, 2.19]1.29[1.01,1.65]0.039Physical violence- less severe ^a^NoREFREFYes1.43[1.04, 1.97]0.78[0.51,1.20]0.257Physical violence- more severe ^a^NoREFREFYes1.87[1.22, 2.86]1.16[0.66,2.04]0.600Sexual violence ^a^NoREFREFYes2.60[1.68, 4.02]1.47[0.97,2.22]0.069.Injuries from partner ^a^NoREFREFYes1.62[1.06, 2.48]0.97[0.52,1.84]0.935Hurt partner unprovokedNoREFREFYes1.51[1.12, 2.05]1.17[0.85,1.61]0.328Partner consumes alcoholNoREFREFYes1.05[0.84, 1.32]0.87[0.67,1.12]0.270Respondent’s father ever beat motherNoREFREFYes1.35[1.07,1.70]1.14[0.91,1.44]0.248I don’t know0.88[0.46,1.69]0.72[0.39,1.30]0.272Coerced to perform unwanted sexual actsNoREFREFYes2.03[1.15,3.57]1.46[0.88,2.41]0.138Prefer not to answer0.45[0.06,3.32]0.34[0.04,2.81]0.316Respondent afraid of partnerNeverREFREFMost of the time2.46[1.43,4.24]1.49[0.81,2.74]0.200Sometimes1.46[1.15,1.87]1.33[1.03,1.70]0.026Respondent hit by previous partnerNeverREFREF< 1 year ago0.17[0.02,1.30]0.09[0.01,0.76]0.027> 1 year ago1.33[0.73,2.41]1.15[0.68,1.92]0.603Don’t remember when1.48[0.86,2.53]1.50[0.91,2.47]0.109Never had another partner0.68[0.55,0.85]0.65[0.52,0.80]< 0.001Person deciding on respondent’s health careRespondent aloneREFREFRespondent and partner1.05[0.84,1.32]1.24[1.00,1.54]0.055.Husband/partner alone1.04[0.69,1.56]0.96[0.60,1.53]0.863Someone else< 0.01< 0.01< 0.01[< 0.01,< 0.01]< 0.001Other14.79[12.79,17.10]6.08[1.04,35.35]0.045*Person deciding on respondent’s large household purchasesRespondent aloneREFREFRespondent and partner0.76[0.60,0.96]0.83[0.66,1.05]0.122Husband/partner alone0.96[0.70,1.30]0.97[0.70,1.35]0.846Someone else2.50[0.86,7.29]0.93[0.31,2.82]0.897Other1.49[0.24,9.42]0.97[0.22,4.22]0.972Person deciding on respondent’s visits to family or relativesRespondent aloneREFREFRespondent and husband/partner0.82[0.64,1.04]0.92[0.73,1.17]0.510Husband/partner alone1.02[0.68,1.52]1.10[0.71,1.69]0.675Someone else6.34[2.84,14.19]3.26[0.97,11.00]0.057.P-value equal or less than: *0.05, **0.005, ***0.0005, ‘.’ 0.1^a^Refer to Appendix A for a full description of the variable^b^Variables were analyzed as continuous variables

Respondents who were uncertain about the acceptability of requesting condom use from a partner with STI had a greater risk of STI compared to those who did not feel it was warranted at all (ARR: 1.72 [CI: 1.11, 2.66]). Women who could refuse sex also had a borderline increased risk of STI (ARR: 1.45, [CI: 1.00, 2.12]). For union status, women living separately from their partners had a higher risk of STI. Unmarried women living with their partners had a lower risk of STI compared to married women. This is evident after correcting for sociodemographic factors and domestic violence. Women who had been in previous unions without a history of domestic abuse had a higher risk of STI as well. Having two non-spousal sexual partners in the past 12 months nearly tripled the risk of STI; however, the confidence interval was wide (ARR: 2.89 [CI: 1.19, 6.99]) with few respondents.

Discussion

Emotional abuse, fear of one’s partner, and reproductive coercion among Filipino women increased their risk of STI. Physical, sexual abuse, and having controlling partners were also linked to STI. A related study found Filipino women in abusive relationships had lower odds of requesting condom use from their partner [23]. IPV victims are at risk for STI complications with lower rates of cervical cancer screening; despite slightly higher rates of screening among Filipino IPV victims, these suggest awareness of sexual health risks in their relationships [29–31]. Women coerced into pregnancy reported partners threatening to leave them for using birth control, contributing to fear around condom negotiation [13, 32]. The relationship between STI and IPV is not always linear. A history of STI increased women’s risk of being in another abusive relationship due to feelings of worthlessness from a past infection; the same feelings made women susceptible to coerced sexual situations, increasing STI risk [33]. In this current study, STI risk increased by 12% when women justified IPV. A related study found that women who believed IPV to be acceptable had lower odds of reproductive health-seeking behavior [34]. Justifying IPV can hinder women from leaving abusive relationships, prolonging their exposure to an increased risk of STI.

Recent condom use, number of sexual partners, and age of first sexual contact were not associated with STI in this population. This study does not negate them as established factors that directly affect STI transmission [15, 25]. Instead, it points to other concerning and influential factors, such as power imbalance in relationships. The temporality of condom use was also not specified in the DHS: whether used before or after contracting an STI. Respondents’ ability to refuse sex increased the risk of STI in this study. Although counterintuitive, other studies show that sexual autonomy and awareness may increase willingness to report and get tested for STI [35, 36]. Uncertainty in asking a partner with an STI to wear a condom increased STI risk. This could also reflect more frequent STI testing among respondents doubtful of their partner’s status. However, there may be inadequate understanding of STI prevention as well since general condom negotiation was not significantly linked to STI. The hesitancy arose when their partner had an STI. Studies found that the lack of sex education in conservative Muslim societies may increase STI risk [6]. However, the lower risk found in this study compared to Catholics could mean muslims are also getting tested less or simply uncomfortable in disclosing their STI history. The variables indicating who decides on the respondent’s healthcare, purchases, and family visits were not strongly associated with STI prevalence. This suggested that not all forms of agency are equally linked to STI risk. Gender dynamics in intimate relationships may be more influential. Lower STI risk among women recently abused by a former partner versus those never abused may not necessarily be meaningful due to the relatively few responses (Tables 1 and 3). Subgroup analysis would provide a clearer picture of its link with STI since studies in other countries have opposing results [37, 38]. Respondents having other people deciding for their healthcare had lower STI risks (Tables 1 and 3) but also had few responses. These other people may be more knowledgeable and effective in making health-related decisions. This finding would be more conclusive with subgroup analysis as well.

The alarming prevalence of domestic abuse justification across education and income levels demands an inquiry into early values formation in basic human rights. Reproductive health counseling should be more transparent in how harmful attitudes can increase STI risk among women. This way, the population will not take these beliefs lightly, knowing certain health outcomes depend on it. School-based sex education may not always be reliable, with inadequate reproductive health pedagogy from educators [39]. Although not all religions were associated with STI in this study, many oppose reproductive health education policies, hindering healthy conversations around sexuality [39]. Conflicted followers make reproductive health implementation and STI control difficult. Instead of complete opposition, sex education can align with some religious values formation, such as abstinence, but also how and why to say no. This develops negotiating skills that strengthen sexual autonomy, which can lower the odds of STI [40]. Another crucial point of intervention is medical visits. Healthcare practitioners in clinics, HIV treatment hubs, and health centers catering to women’s health do not always have the time and training to assess IPV and sexual history appropriately. However, this study shows its importance in STI surveillance. IPV victims with an STI history would also require more than contraceptive use counseling, given the trauma, abusive living situation, and relationship dynamics linked with it. Aside from expanding routine STI testing to IPV survivors, correcting values and perceptions underlying their intimate relationships is crucial in STI control. Patients must be aware and intentional of how values clarification exercises and motivational and cognitive-behavioral elements cultivate healthy sexual practices [40].

This study calls for STI prevention counseling tailored for domestic violence victims. Sexual consent and negotiation skills must be adequately and appropriately integrated into adolescent sex education to prevent victims of domestic violence and STI. Although this study focused on a vulnerable female population, male aggression and the unconditional acceptance of their dominance in households contribute to pervasive abuse. Public health interventions of STI control must be founded on strong values for human rights in both men and women.

Strengths and limitations of the study

Although the sample was representative of each region in the country, responses for the domestic violence module were limited to women who had been married or cohabited with a partner. Self-reporting STI could have underestimated the prevalence. Aggregating STI symptoms with STI history may have overestimated the frequency since abnormal discharge and genital ulcers are nonspecific symptoms. It also was not determined how respondents knew of their STI diagnosis: whether they got tested or simply suspected. Recall bias may have been present, given that the data were collected through a health survey. However, this study was a significant step in identifying STI prevalence on a national scale, beyond the known high-risk groups. It established the added danger of STI among women in abusive relationships.

Temporality of condom use and STI treatment were not specified in the DHS. This study did not include women not in unions or currently having more than two sexual partners. Perceptions of justified domestic abuse of wives by their husbands are assumed to be the respondent’s own opinion. Whether it reflects their husband’s or family’s opinion cannot be determined through the dataset. The number of non-spousal sexual partners and persons making decisions for the respondent may have significant p-values, but weighted frequencies are too small to be conclusive. Although some sexual practices were not consistently associated with STI, they may be contributory factors, perhaps in subgroups of women. This study however, was still able to characterize women at risk of STI in the population.

Conclusion

STI prevalence is linked with IPV and women believing it can be justified. Having a controlling partner and experiencing coercion make it difficult for women to voice their sexual preferences, putting them at risk for STI. This study demonstrates the need for routine STI testing among IPV victims. Reinforcing health centers’ capacity and prompt referral from the Barangay Violence Against Women (VAW) desk would therefore be required. This study also advises including sexual perceptions, practices, living situations, and history of abuse and coercion in STI risk assessment to strengthen STI surveillance. Supplementary training is essential for frontline health workers, who frequently serve as initial responders to IPV survivors.

Compulsory pre-marriage family planning seminars should emphasize human rights and sexual autonomy. Reinforcing these in seminars promotes gender equality and reproductive rights among couples. It is also well within the mandate of the Reproductive Health Law to ensure a rights-based approach as a foundation of sex education. Instilling the values of gender equality, respect, and consent must be strictly implemented regardless of educators’ beliefs. This study shows that women’s harmful attitudes of justifying IPV can increase STI risk. Cultivating women empowerment is therefore crucial in STI prevention, by reducing women’s susceptibility to coercion, imbalanced gender dynamics, and IPV.

Appendix

VariableDescriptionAge in 5-year Groups15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49Residence TypeUrban, ruralEducationHighest attained: none, primary, secondary, tertiaryWealth Index CategoryPoorest, poorer, middle, richer, richestOccupation (Grouped)Not working, Professional/technical/managerial, Clerical, Sales, Agricultural - self-employed, Agricultural - employee, Household and domestic, Services, Skilled manual, Unskilled manual, Don’t knowReligionRoman Catholic, Protestant, Iglesia ni Cristo, Aglipay, Islam, Other Christian (not otherwise categorizable), No religion, Other; not specified if practicing or notCurrent marital statusMarried, living with partnerCurrently residing with husband/partnerLiving with partner, staying elsewhereNumber of days respondent drank alcoholic drinks in the past monthContinuous variable; range: 0–30Age at first sexual contactContinuous age variableRecent Sexual ActivityActive in last 4 weeks, Not active in last 4 weeks - postpartum abstinence, not active in last 4 weeks - not postpartum abstinence; Sexual acts not specifiedWife is justified in asking husband to use condom if he has STINo, yes, don’t know.Respondents’ perception if asking a partner with STI to wear a condom is warrantedTotal lifetime number of sex partnersContinuous variable; range: 1–20Number of sex partners, excluding spouse, in last 12 monthsCategorized: 0, 1, 2Reason for not having sex: husband has other womenNo, yes, don’t knowRespondent can refuse sexNo, yes, don’t knowRespondent can ask partner to use a condomNo, yes, don’t knowHusband or family member pressured respondent to become pregnantNo, yesCurrently residing with husband/partnerLiving with partner, staying elsewhereJustified domestic abuse scoreRespondent’s perception that physical beating of a wife by her husband is justified if wife: goes out without telling husband, neglects the children, argues with husband, refuses to have sex with husband, burns the food; belief that domestic abuse of a wife by her husband is justified in given situations; 0- no (disagree), 1- I don’t know (uncertain), 2- yes (agree). Summed up into a score, continuous variable, range: 0–10.Number of control issues experiencedHusband/partner: jealous if respondent talks with other men, accuses respondent of unfaithfulness, does not permit respondent to meet female friends, tries to limit respondent’s contact with family, insists on knowing where respondent is; 0- no, 1-yes; summed up (range: 0–5)Experienced any emotional violenceEver been humiliated by husband/partner, threatened with harm by husband/partner, insulted or made to feel bad by husband/partner, not allowed to engage in any legitimate work,have no control your own money or properties or forces you to work, husband/partner destroy your personal properties, pets or belongings; no, yes (any one of these).Experienced any less severe violence by husband/partnerEver been pushed, shook or had something thrown by husband/partner, been slapped by husband/partner, punched with fist or hit by something harmful by husband/partner, had arm twisted or hair pulled by husband/partner; no, yes (any one of these).Experienced any severe violence by husband/partnerEver been kicked or dragged by husband/partner, strangled or burnt by husband/partner, been threatened with knife/gun or another weapon by husband/partner; no, yes (any one of these).Experienced any sexual violence by husband/partnerEver been physically forced into unwanted sex by husband/partner. been forced into other unwanted sexual acts by husband/partner, been physically forced to perform sexual acts respondent didn’t want to; no, yes (any one of these).Experienced any of these actions from husband/partnerEver had bruises because of husband/partner’s actions, had eye injuries, sprains, dislocations or burns because of husband/partner, had wounds, broken bones, broken teeth or other serious injury; no, yes (any one of these).Respondent ever physically hurt husband/partner when he was not hurting herNo, yesHusband/partner drinks alcoholNo, yesRespondent’s father ever beat her motherNo, yes, don’t knowCoerced to perform unwanted sexual actsNo, yes, refused to answer/no response. Specific sexual acts not specifiedRespondent afraid of husband/partner most of the time, sometimes or neverNever, most of the time, sometimesPrevious husband: ever hit, slap, kick or physically hurt respondentNever, less than a year ago, more than a year ago, yes but don’t remember, never had another husband/partnerPerson who usually decides on: respondent’s health care”Respondent alone, respondent and partner, partner alone, someone else, otherPerson who usually decides on: large household purchases”Respondent alone, respondent and partner, partner alone, someone else, otherPerson who usually decides on: visits to family or relatives”Respondent alone, respondent and partner, partner alone, someone else, other