Griner S, Aiken J, Johnson K, Webb N, Kline N. The role of direct-to-consumer sexually transmitted infection screening for survivors of sexual assault. HPHR. 2023;76. 10.54111/0001/XXX1
Direct-to-consumer screening options for sexually transmitted infections (STIs) may be an innovative, trauma-informed approach to consider for survivors of sexual assault, however, little research has explored women’s perceptions. The purpose of this paper is to explore the perspectives of direct-to-consumer STI screening as a potential method for college women who have experienced sexual assault.
Sexually active college women, age 18-24 were interviewed (n=24) regarding their overall perceptions of direct-to-consumer methods for STI screening. Interviews were analyzed thematically by two coders (Kappa=.83). The data generated an emergent theme that was not included in the a-priori theory-based coding. This theme focused on the potential acceptability of direct-to-consumer methods for women survivors of sexual assault.
Participants discussed that women who survived sexual assault as among those who would benefit from the availability of direct-to-consumer methods for STI screening. They placed survivors at an intersection of barriers that often prevent people from seeking traditional screenings. Subthemes demonstrate that participants considered the survivor’s intrapersonal decision-making and how the survivor must navigate the sociocultural environment of the university. Results indicate that availability of direct-to-consumer methods for STI screening may mitigate sexual assault-related stigma and discomfort associated with reporting or seeking care, such as seeing a physician.
Direct-to-consumer methods may mitigate challenges associated with the current medicolegal approach to sexual assault care by removing potential areas for re-traumatization and providing access to supportive health services. However, further research is necessary to understand the role of direct-to-consumer methods for survivors of sexual assault.
Although direct-to-consumer methods may provide useful STI screening opportunities, social factors contributing to the disparities in sexual assault and sexually transmitted infection rates on college campuses remain priorities for future interventions.
Rates of sexually transmitted infections (STIs), particularly chlamydia and gonorrhea, are high among women of college age (ages 18-24) in the United States.1 In addition to STIs, sexual assault occurs at high rates among university populations, with as many as 28% of college women experiencing at least one incidence of sexual assault since entering college.2 To facilitate STI screening among college women overall, and particularly among survivors of sexual assault, identifying innovative methods for low-barrier STI screening that promote trauma-informed care is necessary. Therefore, the purpose of this paper is to explore the perceptions of direct-to-consumer STI screening – a method of STI screening that can be utilized with limited provider interaction – as a potential method for college women who are survivors of sexual assault.
STI screening is recommended for all sexually active women age 24 or younger.3 Traditional methods of STI screening involve scheduling appointments and interacting with healthcare providers to receive screening and results, which can be inconvenient and increase STI-related stigma.4 Direct-to-consumer (DTC) testing methods are an innovative approach that evolved to address barriers to office-based approaches to STI screening and were in increased demand during the COVID pandemic as in-office care was restricted. The DTC screening process includes: selecting infections for screening, ordering a “kit” from a website, collecting a vaginal swab at home (self-sampling), mailing the kit to a lab, and receiving results online.4 While DTC methods are acceptable methods among college women and address barriers such as interactions with healthcare providers5 and STI-related stigma6, the demographics of the women who may receive the most benefit from these alternative screening methods remains unclear.
Although STI screening is recommended following sexual assault,7 many women do not report their assault experiences8 or seek healthcare, including post-assault STI screening, given concerns about disbelief from others or being re-traumatized.9 Trauma-informed sexual healthcare recommends the use of self-sampling for STI screening10; however, little research exists to examine the perceptions of self-sampling or DTC methods following sexual assault. As part of a larger study focused on developing a DTC STI screening intervention among college women, participants discussed DTC screening options as important and suggested that it aligned with the needs of women who have experienced sexual assault. The purpose of this paper is to explore the perspectives of DTC STI screening as a potential method for college women who have experienced sexual assault.
Sexually active women, ages 18-24 on a large (over 31,000 students), residential college campus in the Southeastern U.S. were recruited using flyers, emails, and social media advertisements. The advertisements included a survey link and, after completing the survey, an option to leave contact information for further participation in an interview. In total, 24 women participated, 12 who had been screened for STIs in the past year and 12 who had not. Interviews were audio recorded and transcribed, and women were given a $25 gift card for their time. The university’s IRB approved this study and all participants provided informed consent.
The interview guide was designed to focus on intervention development using Diffusion of Innovation constructs,11 and without prompt, a theme emerged throughout the interviews suggesting DTC methods as an avenue of care for women who have experienced sexual assault. After identifying this emergent code, two coders analyzed 10% of the transcripts using the codebook which resulted in high intercoder consistency (Kappa=.83). This emergent theme was not consistently related to one specific interview item or Diffusion of Innovation construct.
All participants were undergraduate students, with an average age of 19.5 years (standard deviation=1.1) and had an average of 2.7 sex partners (SD=2.4) in the past 12 months, which includes oral sex, vaginal intercourse, or anal sex. Most of the participants were white (75%) and non-Hispanic (83%). Because the theme of sexual assault was an unprompted, emergent theme discussed by the women, we did not collect information on the individual’s lived experience with sexual assault.
College women identified people who experienced sexual assault among those who would benefit from the availability of DTC methods – placing survivors among those in an intersection of barriers that often prevent people from seeking traditional screenings. Subthemes demonstrate that participants considered the survivor’s intrapersonal decision-making and how the survivor must navigate the sociocultural environment of the university.
“This will really help the people who can’t afford health insurance, who don’t want to go to the doctors, like me or just the kids who don’t want their parents to know, or rape victims.”
– Participant NS7, 18 years old
Participants began to define a gap between the report of rape, sequential forensic exam and testing, and the acknowledgment of a non-consensual experience and need to care for a potential exposure to a STI. College women described sexual assault without articulation of the term; however, participants connected that these individuals need and want an alternative testing option.
“If they’re already sensitive to, “I might have an STD,” or maybe something happened and it wasn’t their choice of getting the STD, rape or something, maybe it’d encourage more people to come in, in general, if something did happen. If they were raped, then they have the option, just to make sure everything’s okay.”
– Participant NS4, 18 years old
“I don’t want to be stereotypical with this, but let’s say, you go to a party, you drink too much and you wake up and you’ve slept somebody and you just don’t remember. This would be a good anonymous way to do that. Something like that, like maybe like you don’t intend to sleep with somebody but it happens anyway. Stuff like that.”
– Participant S12, 19 years old
Participants felt that a survivor of sexual assault should have accessibility to STI testing without exposing them to additional stress. College women understood the critical role of timing with STIs and sexual health outcomes, proposing DTC methods as an equitable opportunity for survivors of sexual assault to obtain care. This recognition extended to the perception that someone who recently experienced sexual assault will not likely seek care, or will seek care after combating their personal trauma. DTC methods, participants stated, may appeal to victims who otherwise would not have sought screening and treatment.
“Well maybe you’ve gone through some traumatic experience and you are seeking help. Not to be graphic, but if you were raped for example. They don’t have to go to a doctor. And those women are less likely to get, they’re gonna be tested, and they’re gonna get a positive result, hopefully not, but if they do then they’re not gonna figure it out years down the line where it’s become a different issue, and a whole other disease. You start taking care of it then, rather than wait till you’re more comfortable, or you recover from the entire situation, to go get it done.”
– Participant S7, 20 years old
Participants suggested that the possibility of encountering a male physician poses as an additional deterrent to seeking traditional STI screening methods.
“Especially if you have a male doctor, a person who was the victim of a rape wouldn’t want to go to a male doctor for that kind of thing. So it’s not just about thinking about the whole. It’s also about thinking about that one person who needs it.”
– Participant NS1, 18 years old
Participants identified points of campus infrastructure to promote DTC methods as a service offered by the university and increase awareness. Women spoke to opportunities to engage with new students and the locations familiar to current students.
“They could talk about this at orientation for new students coming in. If they let people know that there’s free STD testing, they can mention this. When they go over the whole sexual assault thing, they could mention something like this. You know?”
– Participant S1, 20 years old
“If it was maybe on its own little table or something. Maybe even in the center of victim advocacy? That could be a good place, too.”
– Participant NS11, 18 years old
Women spoke to a rape culture concomitant with on-campus living and the presence of Greek life. Although the university setting produces a higher burden of sexual assault, participants felt that survivors should have every opportunity to monitor their health and DTC methods should be accessible.
“Definitely universities where people are living and actually staying. I feel like there are a lot, I mean not a lot, but there are all sexual assaults and things that happen on campus more than say a commuter college. I mean, unfortunately, that’s a reality and I feel like if any assaults did happen and they were here and this was here that they would probably feel safe to just take that and test themselves with it. Just to know if the person that did that to them had anything.”
– Participant S3, 20 years old
“Where there’s a big Greek culture, there’s also a big rape culture. So, getting tested, especially if you end up in that situation, of course it’s not your fault and you shouldn’t feel like you’re to blame for it, but at the end of the day you should still get tested.”
– Participant NS1, 18 years old
College women described survivors of sexual assault when prompted to discuss the benefits of DTC methods. Participants framed the advantages of these methods within the survivor’s intrapersonal decision making and as a combatant to the rape culture associated with the school. Likewise, existing structures within the university – built to contain endemic sexual violence – were named as potential opportunities to promote the methods. The 2014 Violence Against Women Act amended the Clery Act to require institutions of higher education to provide incoming students with primary prevention and awareness programs, in addition to ongoing efforts for current students. Amendments also included the requirement to inform victims of the available health services in the university or community.12 Participants connected the offering of DTC methods by the university with the university’s legal obligation to provide sexual assault training to students.
Prior research has shown that self-sampling screening methods are better received among college women and that physician interactions may cause concern for privacy and stigma issues.5 This becomes more complex with survivors of sexual assault, because it may also include patient-doctor power, and possibly gender dynamics, where many survivors of rape and sexual assault prefer women practitioners.13 Survivors of sexual assault report avoiding healthcare because of its invasiveness and its ability to trigger memories of previous sexual abuse.14 Patients are less concerned with having tests or procedures than being offered a choice, giving them autonomy over their decisions.9 DTC methods are an important consideration for women who have experienced sexual assault, so they can choose their level of privacy, decide whether to report, and have control over their screening process without additional stress.
Participants identified areas where DTC can be included in medical approaches to sexual assault and STI care. Current clinical practices for treating sexual assault survivors recommend diagnostic STI testing.1 Further, appropriate STI care includes early identification and treatment of infections.15 Participants identified barriers for STI screening following sexual assault, including insurance-related issues and a need to process trauma related to sexual assault before feeling comfortable receiving STI screening. Individuals covered by their parents’ insurance are significantly less likely to be screened for STIs compared to individuals privately insured due to potential privacy issues and out-of-pocket costs.16 DTC methods can mitigate insurance related issues by providing low-cost, accessible, private screening, thus allowing for earlier identification of STIs. Further, DTC methods reduce the need for physician screening following sexual assault, therefore reducing additional stress involved following the traumatic event. Lastly, DTC methods may mitigate challenges associated with the current medicolegal approach to sexual assault care by removing potential areas for re-traumatization and providing access to supportive health services.
Findings from this study are limited by the design and sample. Although the focus of this paper is the emergent theme of DTC methods for screening survivors of sexual assault, we did not collect information for participants about their experiences with sexual assault. This may have influenced the results, as those who were survivors of sexual assault may have responded differently to these interview questions. Additionally, because this was an emergent theme, we did not define sexual assault for the participants, but allowed them to interpret and define sexual assault from their perspective. Also, the study was conducted at a single university that is a large, residential campus in the U.S. South, therefore limiting the diversity of the sample. Future studies should compare campus contexts, including residential versus not, campus size, and geographic location, to identify potential similarities and contextual differences. Further, the study used a cross-sectional design. Given recent social and political movements focused on sexual assault such as the #MeToo Movement and university responses that may include curricular interventions around sexual assault17, a longitudinal study examining DTC STI testing preference and sexual assault factors is needed.
There are also significant health equity and social justice matters that were not addressed in this study. We did not examine the specific perspectives of transgender and gender diverse students, students who are Black, Indigenous, or People of Color, or students with other social identities, such as those experiencing homelessness, who may have divergent needs to those noted here. Given that, it is important that the findings from this small sample are not overgeneralized to the larger population of college women. Addressing other factors associated with the use of DTC methods, including race, socioeconomic status, age, and cultural factors is needed in future studies, as well as their intersectional with sexual assault experiences.
This study revealed perceptions, among a small sample of college women, that DTC methods are a potential option for women who have experienced sexual assault and need STI testing. DTC methods may mitigate sexual assault-related stigma and experiences of discomfort associated with reporting, such as seeing a physician, but are unable to address root causes of sexual assault, such as rape culture. Although DTC methods may provide useful testing STI opportunities, factors contributing to sexual assault and STI prevalence on college campuses remain priorities for future interventions.
This work was supported by the Indiana University-Bloomington Rural Center for AIDS/STD Prevention, Doug Kirby Adolescent Sexual Health Grant, Grant Number N/A. This work was also supported by the University of South Florida College of Public Health Student Research Scholarship, Grant Number N/A.
The authors have no relevant financial disclosures or conflicts of interest.
Dr. Stacey Griner is an assistant professor in the School of Public Health at the University of North Texas Health Science Center. Her research focuses on sexually transmitted infection screening, prevention, and control. She uses implementation science and patient-centered approaches to translate public health research into clinical practice.
Julia is an epidemiologist in the Communicable Disease Branch of the Colorado Department of Public Health and Environment. Her research focuses on using epidemiological approaches in community-based settings to strengthen the local public health infrastructure.
Kaeli is a doctoral student in the School of Public Health at the University of North Texas Health Science Center. Her research focuses on maternal and child health and reproductive health, particularly among racial and gender minority populations.
Nathaniel is a doctoral candidate in the School of Public Health at the University of North Texas Health Science Center. His research uses a systems-thinking approach and focuses on the intersection between the criminal justice system and public health with a focus on the impact of policing on health equity.
Dr. Nolan Kline is an assistant professor in the School of Public Health at the University of North Texas Health Science Center. His research focuses on social and political determinants of health with particular attention to Latinx im/migrant populations and individuals with intersecting racial and sexual and gender minority identities.