Regarding general thoughts and concern about chlamydia, we found that even before receiving test results, women ultimately testing positive for chlamydia were more likely than women testing negative to agree that they “think about chlamydia a lot” (20% vs. 10%, P = 0.02) and that they are “concerned about chlamydia” (46% vs. 33%, P = 0.03). A substantially greater proportion of chlamydia-positive women reported being “concerned about chlamydia” at follow-up than at baseline (80% vs. 46%, P < 0.001). There was no significant change among chlamydia-negative women (40% vs. 33%, P = 0.07).
Relationship status with main partners was similar for chlamydia-positive and -negative women at baseline. Sixty-four (90%) women testing positive had a main partner within the 30 days before baseline and 16% (10/64) broke up with a main partner in that period; 256 (91%) women testing negative had a main partner before baseline and 11% (28/256) broke up (P = 0.30). However, at follow-up, chlamydia-positive women were more likely to report breaking up with a main partner in the previous 30 days (and thus in approximately the month after receiving chlamydia test results); 22 (33%) of 66 chlamydia-positive women with main partners in this period reported breaking up versus 28 (11%) of 249 chlamydia-negative women (P < 0.001). Of the 22 chlamydia-positive women who reported breaking up with a main partner in the 30 days before follow-up, 10 (45%) stated that their chlamydia diagnosis was the main reason for the breakup, 8 (36%) said the chlamydia diagnosis was somewhat the reason, and 4 (18%) said the chlamydia diagnosis had nothing to do with the breakup.
Selected chlamydia-specific concerns evaluated about 1 month after receipt of positive test results are shown in Figure 2. Women had a range of concerns after receiving positive chlamydia test results; only 4% agreed that they “do not really care that much.” Almost all (99%) chlamydia-positive women were worried about having been exposed to other STIs. In addition, most women had concerns related to partner betrayal and trust; 70% felt betrayed by their partners and 87% felt it will be difficult to trust future partners. Only 38% of women stated that their chlamydia diagnoses had not changed their relationships with their partners. Even after receiving results and treatment from a clinician, a substantial proportion of women were worried about future infertility (44%) and that chlamydia would not be cured (37%).
In this longitudinal study, women testing positive for chlamydia had significant increases in anxiety about the sexual aspects of their life and in concern about chlamydia approximately 1 month after receiving chlamydia results, compared with women testing negative. Although chlamydia-positive women had generally worse psychosocial profiles than chlamydia-negative women before testing, chlamydia-positive women did not appear to have marked changes in more global measures of anxiety, depression, and self-esteem after testing. Receiving positive chlamydia test results was associated with some disruption of relationships with main partners, and issues of partner fidelity and trust were prominent areas of concern. In fact, women testing positive for chlamydia had a wide range of chlamydia-specific concerns about 1 month after receiving their test results; only 4% of women stated “I do not really care that much.”
These data provide the first comprehensive, longitudinal assessment of the psychosocial impact of receiving positive chlamydia test results using validated psychosocial scales. Most prior research on the psychosocial impact of a chlamydia diagnosis has involved small qualitative assessments with in-depth interviews of about 20 women each.7,13–15 Major themes identified in the qualitative research included stigma and shame of having an STI, the perception of personal responsibility for sexual health, impact on self-esteem and self-worth, partner fidelity and trust within relationships, impact on future reproductive health and medical consequences, and impact on future sexual relationships.7,13,14 The only previously published quantitative study of receiving positive chlamydia test results was a cross-sectional evaluation of 277 adults in Denmark.16 This study generally supported findings from the qualitative research, in that a portion of women with positive tests had adverse psychosocial responses, especially related to stigma, relationships, and fertility concerns. However, it did not use validated psychosocial scales to compare chlamydia-positive and -negative individuals and was not longitudinal. We observed baseline differences in psychosocial status of women ultimately testing positive and negative, consistent with studies linking adverse psychosocial factors with sexual risk taking and STIs,17,18 which highlights the importance of using longitudinal data. Of note, there has been a longitudinal study of the psychosocial impact of receiving negative chlamydia test results.19 Unlike our study, that longitudinal study found that generalized anxiety decreased after receipt of negative test results; reactions to positive tests were not assessed.
In our study, we found that a substantial proportion of chlamydia-positive women did, in fact, have many of the individual chlamydia-related concerns found in previous research.7,13–16 However, chlamydia-positive women did not have significant changes in global measures of psychosocial functioning 1 month after receiving test results compared with women testing negative. We observed the most profound changes in the MSQ-Anxiety subscale, which measures the tendency to feel tension, discomfort, and anxiety about the sexual aspects of one's life.11 Mean MSQ-Anxiety scores increased by 75% among women testing positive, significantly different from women testing negative. To put the findings in the context, however, mean MSQ-Anxiety scores after a chlamydia diagnosis in this study were still substantially lower than mean MSQ-Anxiety scores observed in a study of patients with a history of symptomatic genital herpes or genital warts.20 Although anxiety about sex and concern about chlamydia may be psychologically distressing, some degree of concern might also be beneficial in terms of receptiveness to counseling about safer sex or chlamydia screening behavior.21 Future studies should explore strategies to minimize unnecessary anxiety related to chlamydia while assessing how responses to chlamydia test results might influence future behavior and prevention efforts.
We observed important disruption of relationships with main partners related to positive chlamydia test results. This may have the largest implications for decision making about the risks and benefits of screening in various populations and the approach to potential false-positive tests. Nucleic acid amplification tests, the most widely used screening tests for chlamydia, are more sensitive than prior tests and are thought to have relatively high specificity.22 However, in low-prevalence populations, even tests with high specificity may lead to a substantial number of false-positives.6 Thus, screening strategies in general, but especially in low-prevalence populations, must take into account the potential harm of incorrectly diagnosing chlamydia infection in a portion of women screened. There have been few, if any, data to guide such decision making. Our data suggest that although most women do not have major changes in general psychosocial well-being after a chlamydia diagnosis, disruptions to relationships and anxiety about sex and future fertility cannot be ignored as potential harms of positive tests.
In the past, additional “confirmatory” testing of positive specimens was suggested as one way to minimize the burden of false-positive tests in low-prevalence settings.22 However, because of the concerns about the use of this approach23 and its substantial economic and logistical costs, this is no longer recommended routinely.24 In addition to avoiding screening in low-prevalence populations for whom such screening is not recommended, such as women aged >25 at low risk,25,26 tailored counseling might minimize psychosocial impact. For example, discussing the fact that most people are unaware that they have chlamydia and that infection may last for >1 year27 may help to alleviate concerns about partner fidelity and trust for some patients. In low-prevalence populations, providers could use their judgment about discussing that, as with any test, a proportion of tests may be falsely positive, while nonetheless stressing the need for patient and partner treatment. Future studies should assess the impact of counseling strategies such as this, as it is unknown whether discussing false-positive tests would minimize psychosocial harm and/or whether it may have the downside of reducing completion of therapy or partner notification and treatment.
The concerns reported by chlamydia-positive women in our study could guide additional counseling messages. More than 95% of the women were worried about other STIs to which they could have been exposed. Thus, it would be important to explicitly state which STIs have been tested for and address concerns about exposures and how to minimize risk. This would be an opportune time to emphasize important STI-related screening and prevention recommendations, such as universal HIV testing and human papillomavirus vaccination for unvaccinated young women.28,29 Over 40% of women testing positive for chlamydia in our study were concerned about future fertility. Providers could point out to patients that, although risk is slightly increased, overall there is a very low long-term risk of adverse reproductive sequelae after a detected and treated chlamydial infection.30 They could also reinforce the value of the current chlamydia testing episode, as well as the importance of future yearly screening, because the greatest risk of infertility would result from ongoing undetected, untreated chlamydial infection. The majority of women in this study were worried about getting chlamydia again. Providers should capitalize on this concern as a “teachable moment” to stress the importance of partner treatment, the need to return for re-screening in 3 months, and ongoing behavioral risk reduction and screening strategies.21,31
This study had several limitations. First, it was conducted in a relatively high-risk population; psychosocial impact may be different in a low-prevalence population with fewer past chlamydia diagnoses and potentially more false-positive results. Second, 50% of participants were lost to follow-up. Although it was reassuring that those who did and did not follow-up had similar baseline demographic and behavioral characteristics, this loss to follow-up may have introduced some bias. Third, unfortunately, we did not have sufficient power to analyze psychosocial outcomes stratified by subgroups, and thus were not able to assess whether there were particular characteristics that might be more predictive of adverse psychosocial outcomes. Finally, we assessed psychosocial concerns at just one point in time about 1 month after receiving test results. We chose this time point to capture more lasting psychosocial concerns than simply immediate reactions to a positive result. However, as with the psychosocial reactions to a positive serologic test for herpes, observed adverse effects may decrease over a longer time period.32,33
In conclusion, we found that chlamydia diagnoses did not appear to have major effects on general psychosocial well-being, but did cause significant increases in concern about chlamydia and in anxiety about the sexual aspects of women's lives, along with disruption of relationships for a proportion of women. These findings do not diminish the importance of chlamydia screening to prevent adverse reproductive health consequences for sexually active young women. Rather, our findings about the psychosocial impact of a chlamydia diagnosis can be used to weigh the risks and benefits of screening in various populations, particularly in low-prevalence settings where false-positive tests are a concern. The impact on relationships and anxiety about sex and future fertility should be considered as potential harms of positive tests. In addition, the range of chlamydia-specific concerns reported by women in this study suggest that tailored counseling messages should be developed to address these concerns, which may minimize the psychosocial impact of a positive chlamydia diagnosis.
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