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.
1. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2008 Supplement, Chlamydia Prevalence Monitoring Project Annual Report 2008. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2009.
2. Stamm WE. Chlamydia trachomatis
infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, et al, eds. Sexually Transmitted Disease. New York, NY: McGraw Hill Medical, 2008:575–594.
3. Centers for Disease Control and Prevention. Sexually transmitted disease treatment guidelines, 2010. MMWR Recomm Rep 2010; 59(RR-12):1–110.
4. Meyers DS, Halvorson H, Luckhaupt S. Screening for chlamydial infection: An evidence update for the US Preventive Services Task Force. Ann Intern Med 2007; 147:135–142.
5. Low N, Bender N, Nartey L, et al. Effectiveness of chlamydia screening: Systematic review. Int J Epidemiol 2009; 38:435–448.
6. Morrison AS. Screening. In: Rothman KJ, Greenland S, eds. Modern Epidemiology. Philadelphia, PA: Lippincott Williams and Wilkins, 1998:499–518.
7. Stoner BP, Buckel C, Gottlieb SL, et al. The psychosocial burden of chlamydial infection: Results of formative qualitative research. Presented at: 18th Meeting of the International Society for STD Research (P2.136); 2009; London, United Kingdom.
8. Rosenberg M. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press, 1965.
9. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: An introductory report. Psychol Med 1983; 13:595–605.
10. Derogatis LR. BSI Brief Symptom Inventory: Administration, Scoring, and Procedure Manual. 4th ed. Minneapolis, MN: National Computer Systems, 1993.
11. Snell WE Jr. The Multidimensional Sexual Self-Concept Questionnaire. In: Davis CM, Yarber WL, Bausenman R, et al, eds. Handbook of Sexuality-Related Measures. Newbury Park, CA: Sage, 1998:521–524.
12. Snell WE Jr. Measuring multiple aspects of the sexual self-concept: The Multidimensional Sexual Self-Concept Questionnaire. In: Snell WE Jr, ed. New Directions in the Psychology of Human Sexuality: Research and Theory. Cape Girardeau, MO: Snell Publications, 2001. Chap 17.
13. Darroch J, Myers L, Cassell J. Sex differences in the experience of testing positive for genital chlamydia infection: A qualitative study with implications for public health and for a national screening programme. Sex Transm Infect 2003; 79:372–373.
14. Duncan B, Hart G, Scoular A, et al. Qualitative analysis of psychosocial impact of diagnosis of Chlamydia trachomatis
: Implications for screening. BMJ 2001; 322:195–199.
15. Pimenta JM, Catchpole M, Rogers PA, et al. Opportunistic screening for genital chlamydial infection. II: Prevalence among healthcare attenders, outcome, and evaluation of positive cases. Sex Transm Infect 2003; 79:22–27.
16. Kangas I, Andersen B, Olesen F, et al. Psychosocial impact of Chlamydia trachomatis
testing in general practice. Br J Gen Pract 2006; 56:587–593.
17. Buffardi AL, Thomas KK, Holmes KK, et al. Moving upstream: Ecosocial and psychosocial correlates of sexually transmitted infections among young adults in the United States. Am J Public Health 2008; 98:1128–1136.
18. Ethier KA, Kershaw TS, Lewis JB, et al. Self-esteem, emotional distress and sexual behavior among adolescent females: Inter-relationships and temporal effects. J Adolesc Health 2006; 38:268–274.
19. Campbell R, Mills N, Sanford E, et al. Does population screening for Chlamydia trachomatis
raise anxiety among those tested? Findings from a population based chlamydia screening study. BMC Public Health 2006; 6:106.
20. Newton DC, McCabe M. Effects of sexually transmitted infection status, relationship status, and disclosure status on sexual self-concept. J Sex Res 2008; 45:187–192.
21. Lawson PJ, Flocke SA. Teachable moments for health behavior change: A concept analysis. Patient Educ Couns 2009; 76:25–30.
22. Johnson RE, Newhall WJ, Papp JR, et al. Screening tests to detect Chlamydia trachomatis
and Neisseria gonorrhoeae
infections—2002. MMWR Recomm Rep 2002; 51:1–38.
23. Schachter J, Chow JM, Howard H, et al. Detection of Chlamydia trachomatis
by nucleic acid amplification testing: Our evaluation suggests that CDC-recommended approaches for confirmatory testing are ill-advised. J Clin Microbiol 2006; 44:2512–2517.
25. Berman SM, Satterwhite CL. A paradox: Overscreening of older women for chlamydia while too few younger women are being tested. Sex Transm Dis 2011; 38:130–132.
26. Bernstein KT, Marcus JL, Snell A, et al. Reduction in unnecessary chlamydia screening among older women at Title X funded family planning sites following a structural intervention—San Francisco. Sex Transm Dis 2011; 38:127–129.
27. Geisler WM. Duration of untreated, uncomplicated Chlamydia trachomatis
genital infection and factors associated with chlamydia resolution: A review of human studies. J Infect Dis 2010; 201(suppl 2):S104–S113.
28. Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep 2006; 55:1–17.
29. Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56:1–24.
30. Low N, Egger M, Sterne JA, et al. Incidence of severe reproductive tract complications associated with diagnosed genital chlamydial infection: The Uppsala Women's Cohort Study. Sex Transm Infect 2006; 82:212–218.
31. McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: The case of smoking cessation. Health Educ Res 2003; 18:156–170.
32. Richards J, Scholes D, Caka S, et al. HSV-2 serologic testing in an HMO population: Uptake and psychosocial sequelae. Sex Transm Dis 2007; 34:718–725.
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33. Miyai T, Turner KR, Kent CK, et al. The psychosocial impact of testing individuals with no history of genital herpes for herpes simplex virus type 2. Sex Transm Dis 2004; 31:517–521.