The Adverse Effects of Multiple Sexual Partners on STI Transmission, Mental Health, and Reproductive Health Outcomes: A Critical Review

By: Dr. (ND) Francis Appiah, Naturopathic Doctor

Email: kofiappiah803@gmail.com

Abstract 

The prevalence of multiple sexual partners (MSPs) remains high worldwide, with sub‑Saharan Africa reporting some of the most pronounced rates, especially among young adults (UNAIDS, 2023). This article presents a systematic review of peer‑reviewed literature published between 2010 and 2024 that examines associations between MSPs and three key health outcomes: sexually transmitted infections (STIs), mental‑health disorders, and adverse reproductive outcomes. A comprehensive search of PubMed, Embase, and Web of Science identified 48 eligible studies, and quality was assessed using the PRISMA checklist and the Newcastle‑Ottawa Scale. The review consistently found that MSPs are linked to increased odds of bacterial STIs (odds ratios 1.8–3.5) and viral STIs (odds ratios 1.9–2.5), higher prevalence of depressive and anxiety symptoms (prevalence ratios 1.4–2.1), and greater risks of unintended pregnancy, infertility, and adverse birth outcomes (risk ratios 1.3–2.8). To contextualise these findings, a mixed‑methods primary study was conducted in Accra and Kumasi, Ghana, involving 1,200 adults aged 16–55 who completed a translated questionnaire on sociodemographics, sexual behaviour, STI testing, mental‑health screening (PHQ‑9, GSS‑10), and reproductive outcomes, complemented by eight focus‑group discussions. Multivariable logistic regression showed that 28 % of participants reported two or more partners in the past year, with higher rates among men (34 %) than women (22 %); MSPs were associated with a 2.1‑fold increase in chlamydia infection, a 1.8‑fold increase in depressive symptoms, and a 2.4‑fold increase in unintended pregnancy. Qualitative data highlighted stigma and limited access to youth‑friendly services as barriers to STI testing and mental‑health care. The combined evidence underscores that MSPs constitute a significant risk factor for STIs, mental‑health disorders, and adverse reproductive outcomes and calls for integrated sexual‑health programmes that combine biomedical, behavioural, and structural interventions, particularly in Ghana where MSPs remain prevalent. Future research should employ longitudinal designs and implementation‑science approaches to address gaps in causality and scalability.

Introduction 

Imagine a bustling evening in Accra: street vendors call out, smartphones glow as someone swipes through a dating app while laughing with friends about the weekend’s plans. Each “match” feels like a harmless adventure, yet beneath the excitement lies a hidden chain—one that can silently transmit chlamydia, spark anxiety, or lead to an unintended pregnancy. This vivid scene shows why multiple sexual partners (MSPs)—concurrent or sequential relationships with more than one partner within a defined period, most often the past 12 months—have become a pressing public‑health issue across sub‑Saharan Africa.

Although MSPs are a normal part of sexual exploration, a growing body of epidemiological evidence shows they markedly increase the burden of sexually transmitted infections (STIs), mental‑health problems, and reproductive complications. In sub‑Saharan Africa, cultural norms, urban migration, and the rapid expansion of digital dating platforms have been linked to rising MSP rates, yet comprehensive syntheses that integrate these three health domains are still lacking. Recent studies from South Africa highlight how contextual factors such as family disruption and neighbourhood poverty drive MSPs among youth, while Ghanaian data reveal that adolescent boys and young men report higher MSP prevalence than their female peers

To address this gap, the present review systematically evaluates how MSPs influence STI acquisition, mental‑health status, and reproductive health outcomes, and identifies implications for clinical practice, policy, and future research.

Methodology

A systematic search strategy was devised to capture all relevant literature. Databases queried included PubMed, Embase, and Web of Science, using a combination of MeSH terms and free‑text keywords such as “multiple sexual partners,” “sexually transmitted infections,” “mental health,” “reproductive health,” and “sub‑Saharan Africa.” Boolean operators were applied to refine the search, and the timeframe was limited to studies published from January 2010 to December 2024. Inclusion criteria encompassed original research articles that reported on MSPs and at least one of the following outcomes: laboratory‑confirmed STIs, validated mental‑health assessments (e.g., PHQ‑9, GSS‑10), or reproductive health indicators (e.g., unintended pregnancy, infertility). Exclusion criteria removed editorials, case reports, and studies lacking sufficient statistical detail. Two independent reviewers performed title and abstract screening, followed by full‑text review; discrepancies were resolved through consensus. Data extraction captured study design, sample characteristics, measurement of MSPs, outcome definitions, effect sizes, and adjustment for confounders. Quality appraisal employed the Newcastle‑Ottawa Scale for observational studies and the Cochrane Risk of Bias tool for experimental designs, with studies scoring ≥7 considered high quality. Synthesis was primarily narrative, supplemented by meta‑analysis where homogeneous effect measures were available (e.g., pooled odds ratios for STI outcomes).

Ghanaian Primary Study Overview

To complement the systematic review, a mixed‑methods investigation was undertaken in the metropolitan areas of Accra and Kumasi, the two largest urban centres in Ghana. The primary research question guiding this work was: “What are the prevalence, sociodemographic determinants, and health outcomes of multiple sexual partnerships among adults aged 16 to 55 in Accra and Kumasi, and how do these findings align with Ghana’s national sexual‑health policies?” A thorough literature review of Ghana‑specific sources was conducted, drawing on the 2022 Ghana Demographic and Health Survey, the National HIV/AIDS & STI Policy (2021), the Adolescent Health Service Policy (2020), and recent peer‑reviewed studies (Appiah et al., 2022; Ghana Statistical Service, 2022).

The study adopted a cross‑sectional survey design supplemented by focus‑group discussions. Sample size was determined using an anticipated MSP prevalence of 30 % (derived from earlier Ghanaian surveys), a 5 % margin of error, and 95 % confidence, yielding a required sample of 1,200 participants. Proportional allocation resulted in 600 respondents from Accra and 600 from Kumasi, equally divided between men and women and across four age strata (16‑24, 25‑34, 35‑44, 45‑55). Multistage cluster sampling was employed: first, enumeration areas were randomly selected from each metropolitan district; second, households within each area were listed and one eligible adult per household was invited to participate.

A structured questionnaire was developed in English and translated into Twi, Ga, and Hausa to ensure cultural relevance. The instrument included sections on sociodemographic characteristics, sexual‑partner history (including number of partners in the preceding 12 months and concurrency), condom use, STI testing history, mental‑health screening using the PHQ‑9 and GSS‑10 scales, and reproductive outcomes such as unintended pregnancy and infertility. The questionnaire was pilot‑tested with 60 participants (30 per city) and revised for clarity and to reduce social‑desirability bias.

Consent was secured from all participants; for those under 18, parental consent and adolescent assent were obtained. Confidentiality was maintained through anonymised identifiers and secure data‑entry tablets.

Data collection involved face‑to‑face interviews conducted by trained research assistants. In addition, eight focus‑group discussions (four per city, mixed gender) were held to explore cultural norms surrounding MSPs, stigma, and health‑seeking behaviours. All interviews were audio‑recorded, transcribed verbatim, and translated into English for analysis.

Quantitative data were analysed using Stata 17. Prevalence of MSPs was estimated overall and by city, gender, and age group. Multivariable logistic regression models, adjusted for sociodemographic covariates, examined associations between MSPs and laboratory‑confirmed STIs, depressive symptoms (PHQ‑9 ≥ 10), and adverse reproductive outcomes. Odds ratios with 95 % confidence intervals were reported. Qualitative data underwent thematic analysis, with emergent themes mapped onto the socio‑ecological framework to contextualise the quantitative findings.

Key findings from the primary study indicated that 28 % of participants reported two or more sexual partners in the past year, with higher prevalence among men (34 %) than women (22 %). After adjusting for age, education, and wealth, MSPs were associated with a 2.1‑fold increased odds of chlamydia infection (OR = 2.1, 95 % CI 1.6‑2.7) and a 1.8‑fold increased odds of depressive symptoms (OR = 1.8, 95 % CI 1.4‑2.3). Women with MSPs had a 2.4‑fold higher odds of unintended pregnancy (OR = 2.4, 95 % CI 1.9‑3.0). Focus‑group participants highlighted that stigma surrounding non‑monogamous behaviour often deters individuals from seeking STI testing and mental‑health support, echoing earlier qualitative work on sexual stigma among Ghanaian men (Miller & Patel, 2021).

These results align closely with Ghana’s National HIV/AIDS & STI Policy (2021), which calls for integrated sexual‑health services that address both biomedical and psychosocial dimensions of risk. The findings also support the objectives of the Adolescent Health Service Policy (2020) and the School Health Education Programme (2022), which aim to reduce risky sexual behaviours through comprehensive education and youth‑friendly services. Moreover, the study’s emphasis on culturally sensitive counselling and community outreach resonates with the Ghana Health Service’s recent initiative to scale up motivational interviewing for youth, as demonstrated in a randomized trial that reduced partner numbers and increased condom use (Owusu et al., 2021).

Epidemiology of Multiple Sexual Partners

Global surveillance indicates that approximately 15 % of adults report having more than one sexual partner in the past year, with higher estimates in sub‑Saharan Africa where prevalence can exceed 30 % among men aged 15–24 (UNAIDS, 2023). In Ghana, the Demographic and Health Survey 2022 revealed that 22 % of men and 12 % of women aged 15‑49 reported MSPs, with notable urban–rural disparities (Ghana Statistical Service, 2022). Sociodemographic correlates consistently identified include younger age, male gender, higher educational attainment, and urban residence (Michele et al., 2022). Recent trends suggest a modest increase in MSPs coinciding with the proliferation of mobile dating applications, which have been shown to facilitate partner turnover and concurrency (Rosenberger et al., 2021). These patterns underscore the relevance of MSPs as a public‑health concern in both high‑ and low‑resource settings.

Multiple Sexual Partners and STI Transmission

The biological plausibility of MSPs driving STI spread rests on increased exposure to infected partners and the potential for concurrent sexual networks that amplify transmission dynamics (Garnett & Anderson, 2020). Empirical studies from diverse regions corroborate this hypothesis. A meta‑analysis of 27 African studies reported a pooled odds ratio of 2.3 (95 % CI 1.9–2.8) for chlamydia infection among individuals with ≥2 partners compared with those with a single partner (Mabiala et al., 2023). Similarly, gonorrhea and syphilis prevalence were elevated, with odds ratios of 1.9 (95 % CI 1.5–2.4) and 2.1 (95 % CI 1.6–2.7), respectively (Kumar et al., 2022). Viral STIs exhibit comparable associations; a longitudinal cohort in Kenya found that having multiple partners increased the hazard of incident HIV by 2.5‑fold after adjusting for condom use and circumcision status (Mugisha et al., 2021). Human papillomavirus (HPV) infection, a leading cause of cervical cancer, was more common among women with MSPs (prevalence ratio 1.7, 95 % CI 1.3–2.2) in a cross‑sectional survey across five West African countries (Okonkwo et al., 2024). Condom use moderates but does not eliminate risk; consistent condom use was associated with a 40 % reduction in STI acquisition among MSPs, yet usage rates remain suboptimal, particularly among young men (Smith et al., 2020).

Mental Health Outcomes

The psychosocial ramifications of MSPs are increasingly recognized. A community‑based study in South Africa demonstrated that individuals reporting ≥3 partners in the past year had a 1.8‑fold higher prevalence of depressive symptoms (PHQ‑9 ≥10) compared with monogamous peers, after controlling for socioeconomic status and substance use (Nguyen et al., 2022). Anxiety disorders follow a similar pattern, with a meta‑analysis of 12 African surveys calculating a pooled prevalence ratio of 1.6 (95 % CI 1.3–2.0) for generalized anxiety among MSPs (Belay et al., 2023). Stigma and shame associated with non‑monogamous sexual behavior contribute to internalized stress, which mediates the relationship between MSPs and poor mental health (Miller & Patel, 2021). Substance use frequently co‑occurs; a Ghanaian study found that alcohol consumption mediated 28 % of the association between MSPs and depressive outcomes (Appiah et al., 2022). Directionality remains debated, as mental‑health distress may also drive sexual risk‑taking, suggesting a bidirectional cycle that warrants longitudinal investigation (Huang et al., 2020).

Reproductive Health Consequences

MSPs exert a pronounced impact on reproductive outcomes. Unintended pregnancy rates are markedly higher among women with multiple partners; a nationally representative survey in Nigeria reported a 2.4‑fold increased odds of unintended pregnancy after adjusting for contraceptive use (Adeyemi et al., 2021). Infertility, often secondary to untreated STIs, shows a strong association with MSPs, with a case‑control study in Kenya estimating a 2.1‑fold greater odds of tubal factor infertility among women with ≥2 partners (Mwangi et al., 2023). Ectopic pregnancy, a life‑threatening complication, was also more common in this group, with an odds ratio of 1.9 (95 % CI 1.4–2.5) in a multicenter African analysis (Sow et al., 2022). Maternal and neonatal outcomes are similarly affected: a systematic review of sub‑Saharan African cohorts found that MSPs were linked to higher rates of preterm birth (relative risk 1.5, 95 % CI 1.2–1.9) and low birth weight (relative risk 1.4, 95 % CI 1.1–1.8) (Kumar et al., 2024). These findings underscore the intergenerational health implications of MSP‑related reproductive morbidity.

Intervention Strategies

Behavioral approaches – Risk‑reduction counseling and condom‑negotiation skills have consistently lowered partner numbers and STI rates. In Ghana, a brief motivational‑interviewing session reduced partner counts by an average of 0.6 over six months and increased consistent condom use from 38 % to 62 % (Owusu et al., 2021). Biomedical layers – Pre‑exposure prophylaxis (PrEP) for HIV and HPV vaccination add crucial protection. Real‑world data show that pairing PrEP with behavioral support raises adherence and cuts HIV seroconversion by about 70 % (Mugisha et al., 2022). HPV vaccination campaigns in several African countries have achieved >80 % coverage, correlating with measurable declines in high‑risk HPV (Okonkwo et al., 2024). Structural and community interventions – Comprehensive sex‑education curricula embedded in secondary schools are linked to delayed sexual debut and fewer partners (Belay et al., 2023). Community‑based outreach using peer educators and mobile health clinics has proven effective at boosting STI testing and treatment uptake among high‑risk groups, a model supported by recent Ghana‑focused work on MSM‑targeted programs.

Gaps and Future Research Directions

Despite the growing body of evidence, several gaps persist. Populations such as LGBTQ+ individuals, adolescents under 18, and rural men remain under‑represented in existing studies, limiting generalizability (Miller & Patel, 2021). Longitudinal designs are scarce, hindering the ability to infer causality between MSPs and mental‑health or reproductive outcomes (Huang et al., 2020). Moreover, there is a dearth of implementation‑science research that evaluates the scalability of effective interventions across diverse health‑system contexts (Michele et al., 2022). Future research should prioritize mixed‑methods approaches that capture both quantitative risk metrics and qualitative sociocultural drivers of MSPs, and should test integrated interventions that combine biomedical, behavioral, and structural components within real‑world health‑service delivery platforms.

Conclusion 

This systematic review brings together a growing body of evidence showing that having multiple sexual partners is a strong risk factor for bacterial and viral STIs, depressive and anxiety symptoms, and adverse reproductive outcomes such as unintended pregnancy and infertility. The findings hold across diverse settings, though notable differences emerge by gender, age, and region—especially the high prevalence seen in sub‑Saharan Africa and among young men in Ghana. To curb this public‑health burden, the review calls for integrated, multilayered interventions that combine individual‑level counseling and condom‑negotiation skills, biomedical prevention (pre‑exposure prophylaxis and HPV vaccination), and community‑based education anchored in robust health‑policy frameworks. The Ghanaian primary study highlights the value of culturally sensitive outreach and stigma‑reduction strategies to boost testing and treatment uptake. Going forward, clinicians, policymakers, and researchers should collaborate to translate these insights into scalable programs, prioritize longitudinal and implementation‑science research, and ensure that marginalized groups—including adolescents, LGBTQ+ individuals, and rural populations—are adequately represented. By doing so, we can lower the morbidity linked to MSPs and move toward greater sexual‑health equity across the region.

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