Over the past 2 decades, there has been a shift from using the terminology sexually transmitted disease (STD) to sexually transmitted infection (STI) in medical and public health vernacular. Two primary reasons have been noted for this transition. First, there is the perception that the term STI may yield less stigma, as the connotation of infection may be thought of as less serious than that of disease.1–3 Any stigma-reducing efforts would be valuable, because STD/STI stigma has been associated with problematic sexual health outcomes.4 Second, STI is arguably a more medically accurate term, because an infection is typically a precursor to a symptomatic disease, and most STDs/STIs are asymptomatic and do not reach a disease state.3,5,6 However, this presumption is undercut by the fact that severe consequences can occur with many silent infections.1 Consensus around the optimal vocabulary has not been reached.1,3,5 Although many prominent sexual health organizations including Advocates for Youth and the American Sexual Health Association are increasingly using the term STI, several other leading organizations, such as the Centers for Disease Control and Prevention and the American STD Association, are not. Furthermore, many organizations and individuals state that they use STD and STI interchangeably.1,3,6,7
Those who have sought to modify STD terminology have done so with the best of intentions for patients and the public’s health. However, health professionals seemed to have led this effort without actual input from the communities they serve. In H. Hunter Handsfield's 2015 Sexually Transmitted Diseases commentary titled “Sexually Transmitted Diseases, Infections, and Disorders: What’s in a Name?” he wrote “To my knowledge, no reported research has studied whether infected persons or those at risk interpret “disease” and “infection” differently. It may be the case, but it seems to me a soft one. (Such a study would be quite simple, inexpensive, and very welcome.)”.1 To our knowledge, only one previous study has explored people’s perceptions of the terms STD and STI.8 This quantitative study, conducted by Royer and Cerf, found that the majority of participants thought the terms STD and STI differed, but the authors were unable to determine in what ways.
Language has the potential to perpetuate or mitigate stigma for sensitive health issues,9 and discrepancies in language between health care providers and patients serve as barriers for effective health communication.8 Further, understanding the values and preferences of communities and patients is a core tenant of evidence-based practice.10 The present study responds to Handsfield's appeal for research comparing people's interpretations of the terms STD and STI and expands on prior research. Using a sample of late adolescents, an age group particularly at risk for STDs/STIs,11 the research questions for the present study were: (1) What are late adolescents’ salient perceptions of the terms STD and STI? (2) How do late adolescents’ perceptions of the terms STD and STI differ?
MATERIALS AND METHODS
As part of a larger study on the sexual health of late adolescents,12 419 undergraduate students from 14 health-related courses at a large public Midwestern university participated in a survey through Qualtrics,13 a Web-based survey program in spring 2016. Participants were randomized through Qualtrics to receive either the open-ended question “What comes to mind when you think of the term sexually transmitted disease (STD)?” or the open-ended question “What comes to mind when you think of the term sexually transmitted infection (STI)?” as their first survey question. The abbreviations were included given their standard usage. This kind of methodological approach is similar to other studies that have sought to compare the connotations people have about other health-related terminology14 and prevents contamination that could occur by asking participants to think about both terms.
Participants' demographics, sexual behavior, and STD/STI knowledge are reported as background characteristics for the sample. Sexual behavior questions were taken from the American College Health Association—National College Health Assessment.15 STD/STI knowledge was measured by an established modified STD/STI knowledge test,12,16 in which the resulting knowledge score ranged from 0 to 30, with higher scores representing more accurate STD/STI knowledge.
Data were originally exported into IBM SPSS Version 24.17 After removing 6 cases without responses to the primary measure, 205 participants were in the STD condition and 208 were in the STI condition. Frequency analyses were done to determine participants’ background characteristics. Random assignment was assessed by comparing the STD and STI conditions for all of the variables listed in Table 1 using an independent-samples t test for STD/STI knowledge and cross-tabulations and χ2 analyses for all other variables. There were no significant differences between the groups.
Participant IDs and responses to the STD or STI open-ended question were divided based on condition and copied into separate Microsoft Excel documents for analysis. Conventional content analysis was conducted to identify themes among each set of responses.18 Subthemes were determined within overarching themes as appropriate. The second author conducted the primary coding and developed the initial codebook. The first author reviewed the fidelity of the codes, and the authors discussed a small number of differences in perspective; consensus was reached in all cases. Because many participants included multiple fundamentally distinct perceptions within a single response, coding was nonmutually exclusive. Exemplar responses were selected for each theme and are reported verbatim.
The themes were then entered into the original SPSS file and data in the form of endorsed theme/not endorsed theme from the Excel files were merged with the SPSS data set. Cross-tabulations with the χ2 statistic were done in SPSS to compare the overarching themes between the STD and STI conditions. Significance was set a priori at P less than 0.05. The study was approved by Indiana University's Institutional Review Board.
Participant characteristics for the STD and STI conditions are presented in Table 1. Table 2 summarizes the themes identified across both groups, the frequency count and percentage of participants in each group that endorsed each theme, and the statistical comparison between the 2 groups for each theme. Participants’ mean number of themes in a single response was 1.32, with a range of 0 to 4.
The most common theme stated across both the STD and STI groups was contracted through sex, (STD: 55.1%; STI: 48.1%; χ2(1) = 2.052, P = 0.152). There were 2 subthemes. The first, sexually transmitted, encompassed responses such as “I think of a disease that is spread from person to person through sexual acts.” The second subtheme, unprotected sex, had responses like “When I think of STI, unsafe sex comes to mind.” The second most frequently mentioned theme among both groups was specific sexually transmitted conditions (STD, 24.9%; STI, 26.0%; χ2(1) = 0.064, P = 0.800). Participants specifically mentioned the subtheme HIV/AIDS more than any other STD/STI. Other STDs/STIs were also mentioned by a substantial number of participants. The most frequently cited non-HIV/AIDS conditions across the groups were herpes (n = 40), chlamydia (n = 24), and gonorrhea (n = 20).
Many participants’ responses represented that they thought STDs/STIs were severe, (STD: 17.6%; STI: 12.0%; χ2(1) = 2.519, P = 0.112). Subthemes included serious, in which participants typically made general remarks such as “a bad problem”; incurable such as “cannot be cured”; and even death. As 1 participant wrote, “I think about the bad outcomes caused by STIs, such as infection, pain, and terrible things, such as infertility or death.” Participants also revealed negative emotional affect, with significantly more people in the STD group endorsing this theme (STD, 10.7%, STI, 4.8%; χ2(1) = 5.069, P = 0.024). Most of these participants believed that STDs/STIs were gross. For example, “gross is the word that comes to mind, because STDs are nasty” and “disgusting and transmittable.” Some participants also mentioned that STDs/STIs were scary and embarrassing.
Participants thought about the types of people who get STDs/STIs (STD, 6.8%; STI, 10.6%; χ2(1) = 1.822, P = 0.177). Many of these responses referenced promiscuity. For example, “People having sex with too many people.” Some participants categorized people more generally, such as “Disease that is caused by sexual relationship with wrong people.”
Participants also thought of physical symptoms (STD, 5.4%; STI, 7.2%; χ2(1) = 0.596, P = 0.440). For example, “some sort of irritation, rash, itchiness, etc on ones genitals.” Some participants referenced that both STDs and STIs were preventable (STD, 4.4%; STI, 6.7%; χ2(1) = 1.075, P = 0.300). For instance, “It is something that can be preventable through abstinence or protection.” A few participants also thought of STDs and STIs as being treatable/curable (STD, 3.4%; STI, 6.3%; χ2(1) = 1.801, P = 0.180), with comments, such as “Usually can be treated with meds” and “An infection that results from having unprotected sex, that you can potentially get rid of.” Significantly more participants in the STD group mentioned that STDs were common (STD, 4.4%; STI, 0.96%; χ2(1) = 4.682, P = 0.030), with comments such as “common diseases that are easily contracted through sexual intercourse.”
There were 2 themes that emerged only within the STI group. The first was the general category of STDs (STD, 0%; STI, 4.8%; χ2(1) = 10.100, P = 0.001). Some participants simply wrote “STDs” whereas others provided a longer response, such as “STD’s, HIV.” Within the STD group, no participants wrote “STIs” or “STDs” as a central part of their response. The other STI-only theme was site of infection (STD, 0%; STI, 4.3%; χ2(1) = 9.068, P = 0.003). In these responses, participants wrote about where on the body the infection was situated, most commonly the genitalia. For example, “infection of women's or men's vagina or penis.”
Overall, participants' salient perceptions of the terms sexually transmitted disease and sexually transmitted infection had substantial overlap. Nine overarching themes were shared across the STD and STI groups. Some themes were more factual in nature, such as contracted through sex and specific sexually transmitted conditions. Yet these responses also revealed potentially concerning misperceptions. Unprotected sex came to mind for almost a quarter of the participants. Although using condoms and other protective barriers can substantially reduce STD/STI risk, it is troubling that young people may be unaware that protected sex does not eliminate their transmission risk.19 Interestingly, HIV/AIDS was the most frequently cited STD/STI, yet it is one of the least commonly diagnosed STDs/STIs in this population. HPV, on the other hand, is very prevalent among late adolescents,20 and was rarely mentioned. Although all STDs/STIs are stigmatized among young people, HIV has been found to have the greatest level of stigma.21 It is therefore possible that HIV would be particularly salient among youth despite their being at higher risk for other STDs/STIs.
Participants expressed some disconcerting reactions to STDs and STIs. Many participants used words such as “nasty,” and “disgusting” in their responses. Other research has likewise found that people have strong emotional reactions at the prospect of having an STD/STI,22,23 which could be related to social stigma or the misperception that STDs/STIs have physical symptoms, a belief also identified in the current study. Participants’ assumptions about the kinds of people most likely to acquire an STD/STI may also exemplify the highly stigmatized nature of these conditions.4,21 Although having multiple partners is an STD/STI risk factor,24 the language that participants used was judgment-laden. STDs/STIs may be a condition that nonaffected individuals feel happen to “other people.” Hoff and colleagues found that while 9 of 10 people thought STDs were a sexual health concern, far fewer were personally concerned about contracting them.25
Participants’ perceptions that STDs/STIs were severe may have both positive and negative implications. The perceived severity of a medical condition can be a facilitator in helping people to take steps to prevent or minimize its consequences.26 However, this belief may have less utility if it is founded on misinformation and fear, particularly if people do not feel self-efficacious to take action.27 Perhaps relatedly, several participants immediately thought of physical symptoms associated with STDs/STIs, despite the fact that most are actually asymptomatic.24 These perceptions could be a result of the sexuality education participants received. Abstinence-only sexuality education, which has been found to use fear appeals, was at its peak when many participants were in middle and high school.28 Regrettably, health-promoting perceptions, such as preventable and treatable/curable, were some of the less commonly endorsed themes.
Only 2 of the shared themes had statistically different endorsements, although the overall discrepancies were somewhat small. STDs were perceived as more common than STIs. This finding is contrary to the expectation that the term STI would better normalize these conditions. However, the term STD provoked more negative emotional affect than the term STI, which is consistent with the goals of the terminology change. Two of the themes, although fairly small in number, were specific to the STI group only. It appears that some people, including those in the younger generation, still think of STDs even when they encounter the term STI. This is perhaps unsurprising given the inconsistency in terminology used in the U.S. Additionally, the term STI led more people to think of a site of infection than did the term STD. It is possible that the word “infection” has the connotation of being more location-specific than a “disease.”
This study provides a qualitative lens to Royer and Cerf’s work.8 Although it is difficult to compare findings given different methodological approaches, both studies yield the same primary implication—that “changing terminology may not help to reduce the stigma associated with these illnesses.” Ultimately, although there were some differences between participants’ perceptions of the terms STD and STI, overall there were many more commonalities. This study has revealed that a shift in language is not enough. The misinformation and stigma depicted across the STD and STI groups is where the real work must be done. Evidence-based sexuality education for young people, tailored patient communication by health care providers,29 and widespread health communication campaigns for the general public alongside reframing STDs/STIs in the context of sexual health promotion30 will likely serve as more effective strategies.
There are limitations that should be taken into consideration when interpreting the study’s findings. Although there was an ample sample size, particularly for content analysis, the study took place at 1 institution among college-enrolled students. Participants were in health-related courses; however, most students were not health-related majors. Also, this study sought to understand participants' salient perceptions of STDs/STIs rather than provide a comprehensive representation of participants’ STD/STI beliefs in their entirety. Just because participants did not mention a particular theme in their response does not mean they would not endorse the theme if asked as part of a more quantitative approach. This study could provide the formative research needed for a larger quantitative study on beliefs about STDs/STIs and potential differences between people's perceptions of the 2 terms. Other study methodologies, such as asking participants to respond to case studies reflecting real-life scenarios, may also prove valuable. Future research should determine if the study findings can be replicated among other priority populations. Further, it would be useful to understand the relationship that STD/STI knowledge and stigma may have with the identified beliefs.
This study has addressed an important gap in research and practice on perceptions that late adolescents have about the terms STD and STI. The results expose several problematic perceptions that persist regardless of the terminology used. It is clear that health professionals have more work to do to educate the public and demystify these prevalent and consequential health concerns.
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