Sexual behavior and sexually transmitted diseases among the female partners of inmates*

ABSTRACT Objective: to analyze the sexual behavior of the female partners of inmates and estimate the prevalence of sexually transmitted diseases. Method: cross-sectional, quantitative study involving 349 female partners of inmates. The Estudo de Comportamento Sexual [Sexual Behavior Study], an instrument validated in Brazil, was used to collect the data. The Statistical Package for the Social Sciences, version 20 was used in the statistical analysis. Results: 41.2% of the female partners of inmates reported a prior history of sexually transmitted disease. Association was found between having more than one partner in the last 12 months (<0.006), sexual violence (<0.001), having sex for money (<0.001), under the influence of alcohol (<0.001), and under the influence of drugs (<0.005). The variables associated with sexually transmitted infections in the logistic regression were: having more than one partner in the last 12 months, sexual violence, sex for money, and under the effect of alcohol or drugs. Conclusion: The number of partners, sexual violence, sex for money, and under the influence of alcohol or drugs are sexual risk behaviors that increase the prevalence of sexually transmitted infections among the female partners of inmates.


Introduction
The increased prevalence, frequent occurrence and consequences of Sexually Transmitted Diseases (STD) among women reveal the need to address these issues from a gender perspective. Biological, cultural, and socioeconomic factors contribute to the high incidence and prevalence of STD and infection by Human Immunodeficiency Virus (HIV) among women (1) . A large share of women, in particular those subject to greater social vulnerability do not adopt protective measures against STD, due to difficult access to preventive devices and services, lack of knowledge, gender issues and/or unstable relationships. More than 20 types of diseases are transmitted through sexual contact and represent a severe public health problem given their consequences for health and social and economic repercussions (1)(2) .
STD are contagious infections, the most frequent form of transmission is through sexual intercourse (mainly through vaginal, oral or anal sex). They are caused by various infectious agents and cause a large range of symptoms and clinical manifestations, though, in most cases, these conditions may progress with few or no symptoms (2) . Currently, STD are a public health problem worldwide, imposing increasing socioeconomic costs, not only because of the high number of infected individuals but also because of their increased incidence in many countries, and more importantly, because of the consequences for sexual, reproductive and maternal-fetal health, and ease with which infections are acquired and transmitted. It is, however, difficult to establish a single sexual risk behavior (3) .
Populations with a history of incarceration and their sexual partners are exposed to a high risk when compared to populations not exposed to incarceration. Behaviors such as having multiple partners, concomitant partners, and unprotected sex predispose and influence the risk of STD, however, vulnerability, social and economic instability and substance use, such as alcohol and drugs, also contribute to increased risk among women with imprisoned partners.
The following stand out among factors that potentially determine the transmission of these diseases, which suggest high vulnerability: irregular or infrequent use of condoms, low educational level, multiple sexual partners, sex under the influence of alcohol and/or drugs, sexual violence, sex for money, and low involvement with preventive measures (4) .
The environment of prisons offers physical and psychological risks and the risk of infectious diseases due to the heterogeneity of incarcerated individuals (5) . In this sense, the vulnerability of both prisoners and their family members, especially that of their partners, should be taken into account and be a priority in the planning of care actions considering the risk behaviors of this population. Some factors related to vulnerability include lack of access to information and educational activities, addressing how STDs/HIV are transmitted and prevented; lack of motivation or sensitization to assess and understand the risk of infections to which they are exposed; lack of skills to adopt preventive measures including safer life habits (1) . In relation to the female partners of inmates, it is necessary to become familiar with the National Comprehensive Care Policy on Persons Deprived of Liberty (PNAISP). One of its objectives is to consider the health/ disease/care delivery continuum beyond the individual, including his family and social networks (6) .
Actions implemented in Brazil to prevent and control STD/HIV primarily focus on the use of condoms in every sexual intercourse. Approaches recommending decreasing the number of partners, sexual abstinence or monogamy, are unfeasible or unviable and disrespect the right of people to decide when and with whom they keep sexual intercourses, thus, these approaches are not part of the preventive strategies implemented in Brazil (7) . Addressing the various sexual practices, highlighting male and female (biological and gender-related) vulnerabilities is essential for men and women to perceive the risk situations they are exposed to, not only considering their own sexual behavior, but also that of their partners (8) .
Brazil is the fourth country in the world with the highest number of prisoners -there are currently 623,000 inmates serving sentences in prisons and precincts of police stations, and this number tends to increase by 7% a year (9) . With this high number of inmates and progressive increase every year, the estimate is that thousands of women have intimate visits with their partners and are considered a vulnerable population, exposed to risks and behaviors that may result in SDT or other diseases. The third penitentiary is located in the Southeast of the state and belongs to the 7 th Regional in the city of Women older than 18 years old, partners of inmates, who had made intimate visits to their partners for more than six months and voluntarily provided their consent, participated in this study. Women with other levels of kinship (e.g., mothers, daughters and others) and those who were under the influence of alcohol or other drugs were excluded.
The women were randomly selected on the days and hours scheduled for intimate visitation with their partners in the penitentiaries. Data collection was conducted in the prison's patios where women waited for their visits, ensuring that the interviews were private and remained confidential.
In order to establish rapport with the participants, the can assess quality of life in diverse groups and situations (12) .
Afterwards, the semi-structured questionnaire Ecos, model II, with 38 questions was applied. It was adapted for application in a field survey addressing only women. The questionnaire Ecos was developed by Abdo and collaborators in three models, models I, II and III.
Model II was modified and applied with guiding questions directed to the population of female partners of inmates and considering their sociodemographic profile. The merit of this instrument was not only revealing data on sexual risk behavior but also portraying different aspects and providing a profile of the current and past sexual behavior of the population under study (13) .
The first part of this instrument is intended to portray the profile and sociodemographic characteristics of the participants, as well as to screen for risk factors related to lifestyle (consumption of alcohol, tobacco, illegal drugs and physical exercise). The second part of the instrument is intended to identify STD, asking whether they had some type of STD diagnosed by a physician currently or in the past, as well as types of sexual behavior (age of the first sexual intercourse, number of partners in the last 12 months, sex under the influence of alcohol, sex under the influence of drugs, sex for money, sexual violence).
The participants should answer yes or no.

Results
From the total sample (n=349), 39.0% (n=136) were from Piraquara; 39.8% (n=139) from Londrina; and 21.2% (n=74) from Francisco Beltrão. Most women (51.9%) were aged between 20 and 29 years old. With regard to race, Caucasian and mixed race were the most frequently mentioned, 41.5 and 42.1%, respectively. With regard to marital status, 49.0% reported a stable relationship, that is, they lived with their "partners" but were not officially married; 21.2% were single; and 29.8% were married.
The number of children was also verified; more than half (53.3%) had one or two children. The dependent variable STD stands out as 41.2% of the women reported they currently had or previously had some type of STD.
Finally, the median age these women initiated sexual life was 14 years old. Martins DC, Pesce GB, Silva GM, Fernandes CAM.
Using robust logistic regression,   (14) . Note that the type of sexual behavior reported by the female partners of inmates may be associated with a low educational level and social vulnerability, as these aspects are directly linked to information access, Rev. Latino-Am. Enfermagem 2018;26:e3043.
negatively influencing sensitization and understanding on how to prevent and treat certain diseases (15) .
This study's results show that 40.8% of the women reported more than one sexual partner in the last 12 months, and 49.7% of them reported a prior STD. This result contrasts with that reported in a study conducted with 175 female partners of inmates in the United States, which revealed that 50% of the women reported having other sexual partners while their partners were incarcerated. Men with a history of incarceration are three to six times more susceptible to acquire HIV and other STD than men with no history of incarceration (16) .
It poses increased risk to the female partners of inmates because, in addition to the risks these women are individually exposed, there is the sexual risk behavior of their incarcerated partners (17) .
Women whose partners are imprisoned lack the emotional and material support a present partner provides in the family context. This lack of support and resources may lead these women to seek another partner to fill in the gaps left by their imprisoned partners (16,18) . Thus, the participants consider this behavior to be acceptable, especially in situations in which their partners may receive resources in exchange for sexual intercourse within the prison (16) . Researchers conclude that women who engaged in other relationships when their partners were incarcerated were more likely to be young and engage in other sexual relationships and present risk behaviors such as the use of alcohol and drugs (18) .
This study also shows that 36.1% of the female partners of inmates who reported receiving money for sex currently have or have had STD and were 3.8 times more likely to acquire SDT. A longitudinal study using a qualitative approach and addressing the female partners of Afro-American inmates highlight that the involvement of these women with other partners is also associated with financial issues, as they attempt to ensure shelter and support for their families (4) .
Additionally, there are factors directly associated with SDT among women who make sex for money, such as a high number of sexual partners and unprotected sex together with the consumption of illegal drugs and alcohol, exposure to prisons, low education and socioeconomic marginalization (7,19) . behavior is having unprotected sex, which increases the risk of acquiring STD (20) .
A study conducted with 673 women in Africa conclude, through a control group, that women who consumed alcohol were more likely to have multiple partners and partners who presented a risk behavior. reported not using condoms with casual partners during a 12 month-follow-up (20) .  (21) .
Drugs are believed to cause uninhibitedness and increase sexual desire, leaving individuals more prone to sexual risk practices (21) . Additionally, many people use drugs to relax in order to reach out to someone they intend to establish a relationship with and individuals prone to risk behaviors may concomitantly use alcohol and other drugs (22) .
Note that sexual violence appears very influential in this study and is an aspect that also presents risk with regard to STD, as 57.1% of the women who experience sexual violence also acquired some type of STD. Such information shows that women in a situation of violence cannot even protect themselves or choose sexual behaviors as they submit themselves out of fear and are forced to practices that expose them to such diseases. A situation that is common among women, victims of sexual violence, is to submit to marital sex without desire, which may be associated with the fact that women may not perceive unconsented sexual intercourse as violence and become vulnerable to STD/HIV (23) . The consequences of sexual violence go beyond the physical and psychological spheres, as these women are directly exposed to an "undesirable pregnancy, STD, HIV/AIDS infection, depression, panic syndrome, anxiety and psychosomatic disorders" (24) .
The aggressions experienced by the female partners Martins DC, Pesce GB, Silva GM, Fernandes CAM.
of inmates may be linked to alcohol and other drugs abuse because, when their partners are not under the influence, their behavior may be calmer (21) . Additionally, the use of alcohol and drugs may lead a man to force his partner to practice sex, aggravating cases of violence even further (23)  Actions to promote the health and civil rights of the female partners of inmates is essential for these women who become invisible for the judicial and health systems, which only focus on the improved behavior of inmates when allowed to have intimate visitations, not taking into account the psychological conditions and specific health conditions of women, or STD prevention and treatment when necessary (5,26) .

Conclusion
This study's results show association of highly risk sexual behavior for the emergence of sexually