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Stigma, Misconceptions Impede Chlamydia and Gonorrhea Screening
American Social Health Association (ASHA)
Fred Wyand and Deborah Arrindell

Chlamydia and gonorrhea infections are often unrecognized and undiagnosed. Over 1 million cases of chlamydia were reported to the Centers for Disease Control and Prevention (CDC) in 2006, but estimates place the true incidence in the United States at nearly 3 million cases.^1,2 The situation is similar with gonorrhea: over 700,000 infections are estimated to occur in the United States each year, fewer than half of which are reported to CDC.³

The highest rates with both infections occur in young people, with females ages 15-24 years bearing the heaviest burden.⁴ Both chlamydia and gonorrhea are often asymptomatic and, if untreated in women, can cause pelvic inflammatory disease (PID), chronic pelvic pain, ectopic pregnancy, and infertility.⁵

Racial disparities are also a pressing issue. The rates of chlamydia and gonorrhea among African-Americans are eight and sixteen times higher, respectively, than for whites. Hispanics and Native Americans are also disproportionately impacted. These striking inequities are fueled in part by poverty, lack of access to health care, distrust of health systems, inadequate access to health care, and numerous other social factors. ⁷

Federal and professional recommendations call for annual chlamydia screening for all sexually active women age 25 and younger, and chlamydia and gonorrhea screening for women with risk factors (such as having a new partner or multiple partners, or a history of gonorrhea infections).^8,9

Nucleic acid amplification tests (NAATs), the most sensitive chlamydia testing available, permits testing of asymptomatic individuals through non-invasive sampling techniques such as urine-based screening or self-collected vaginal swabs.¹⁰ Non-invasive screening for adolescents is important, as this technology also allows testing to occur outside of traditional clinical settings, such as in schools or at home. ¹¹

In spite of published guidelines, the availability of reliable tests, and the complications that can arise from undetected infections, screening rates with both chlamydia and gonorrhea remain low. National surveys indicated fewer than half of providers screen young female patients for chlamydia. ^12,13

So why aren’t more individuals screened, especially those most at risk? Reluctance among healthcare providers to test for chlamydia and gonorrhea often stems from lack of awareness of sexually transmitted disease (STD) prevalence among young people, perceptions that their patients are not sexually active or at risk, not knowing PID is associated with undetected chlamydia, and lack of comfort discussing STDs. ^14,15

With patients, lack of financial resources and insurance are obvious obstacles, but the tale is much more complex. Patient barriers to screening include perception of not being at risk, time and transportation issues, and fear of testing.^16,17 . Regarding worries about testing, concerns might be alleviated if patients understand that gonorrhea and chlamydia testing can be done with urine specimens.

While targeting knowledge gaps and correcting misperceptions among both patients and providers would be helpful, chlamydia and gonorrhea screening uptake would likely be enhanced by addressing the psychosocial aspects that surround STD discussions. Patients commonly report concerns about stigma and privacy as reasons to not seek STD testing, and many say they fear their provider will regard them as “dirty.”^18,19,20

So what can clinicians do to put patients more at ease when talking about matters of sexual health? In the American Social Health Association’s STD Counseling and Treatment Guide, Alexander and Clarke point out that patients are more comfortable and receptive to discussions about STDs when they are fully dressed, and when counseling takes place before and after examinations (as the exam process itself can be stressful and distracting). It’s also important to reassure patients who may be fearful of confidentiality issues.

It’s helpful if both patient and provider are seated in close proximity with no barriers (like desks) between them. An open, relaxed manner and good listening skills are key, as patients take cues and will likely sense if the provider is tense or seems distracted.²¹ Augment counseling provided in the office by offering education and support resources (fact sheets, brochures, web sites) as appropriate.

Messages for Patients after Diagnosis

Though cured quickly and easily with antibiotic therapy, reinfection is common with both chlamydia and gonorrhea. Patients should be instructed not to have sex until all partners have been treated. Reinfection leaves women more susceptible to PID, so females treated for either infection should be informed about the importance of retesting in approximately 3 months.²² Also, counsel about safer sex practices, and stress that oral sex and anal intercourse are risks for STDs, including chlamydia and gonorrhea.

A key element in preventing reinfection is treatment of sex partners, many of whom will be infected but have no symptoms. Given the myriad issues that hamper access to health care, having partners go for evaluation and treatment isn’t always realistic. According to CDC’s Sexually Transmitted Treatment Guidelines 2006, partner-delivered antibiotic treatment can be considered (in states where permitted) with cases where sex partners are unlikely to seek care on their own.

Support after Diagnosis

For many, the psychosocial impact is the most difficult aspect of an STD diagnosis. Many who contact ASHA experience anger, sadness, and tremendous shame in the wake of learning they have an STD, and often the embarrassment is so great they can’t turn to family and friends for support. This leads to a sense of isolation, exacerbating emotions that are already strong and raw.

In response to this need, ASHA has created a set of interactive STD message boards where patients and partners receive information and sensitive support. These no cost, anonymous forums—all of which are moderated by ASHA staff—offers venues for general STD discussions as well as a board dedicated to chlamydia. ASHA is always committed to reaching those who might be overlooked in sexual health discussions, so in that spirit we even have a forum just for senior citizens!

The ASHA STD forums are located at http://www.ashastd.org/phpbb/index.php