Background
Chlamydia trachomatis (CT) is a much underestimated sexually transmitted infection (STI) and worldwide diagnoses of CT have increased in recent years [
1‐
4]. CT is the most diagnosed bacterial STI among sexually active people, and has potential reproductive sequelae. A major risk group for CT are young heterosexual people below 25 years of age. They are targeted by health care professionals using key control strategies that encompass testing, treating, and partner notification (PN), to interrupt the inherent transmission chain [
5,
6]. Several associated factors, which influence the uptake of these strategies, have been identified. A systematic review on CT testing in young women revealed that the uptake of CT testing was impeded by ignorance and inaccurate information, denial, moral connotations, stigma, fear, anxiety, confidentiality and privacy concerns, and pragmatic factors such as cost and test discomfort [
7]. Other barriers among women and men include the embarrassment and shame associated with seeking care [
8,
9], the asymptomatic nature of the infection [
6,
10], fear of a positive test result [
6,
11], and perceived STI-related stigma (i.e., fear of being subjected to negative societal attitudes and discrimination) [
12]. Facilitators included accurate knowledge, feelings of personal relevance, multiple test options (i.e., home-based test kits, self-administered swabs), free tests, and support with diagnosis [
7]. The process of PN is also influenced by several factors. Barriers to notifying a sex partner, as revealed in a systematic review of PN, included stigma, guilt, blame, possible relationship breakdown, violence, and missing contact details [
13]. Partner notification can be facilitated by using Patient-Delivered Partner Therapy (i.e., partners are treated via the patients by providing prescriptions or medications without a medical personal evaluation), online notification, and home-based test kits [
13].
To overcome barriers and explore the facilitators of CT testing and PN among young people, innovative care methods have been developed in addition to the regular care provided by STI clinics and general practitioners in for instance Europe Australia, and US [
13‐
20]. These new methods include web-based programmes that utilise email and text messaging, alongside home-based sampling [
18‐
20]. These programmes aim to facilitate testing in high-risk groups of individuals who are connected in sexual networks and/or social networks. Peers from such networks surrounding CT positive individuals are important targets in CT control, as they typically show similar high risk, for example with respect to unprotected sex or sex with a CT positive person [
21]. Communication in social networks is associated with the sexual behaviour among friends in these networks [
22]. Modelling may also play a role; the actual behaviour of peers may influence a person’s behaviour, for example regarding sexual behaviour, but also regarding CT testing [
23]. Therefore, essential components of care methods that aim to reach high-risk networks include the disclosure of CT testing behaviour to sexual and social network members and the encouragement to get them tested using for example the internet and home-based sampling. Successful disclosure and encouragement could thus potentially lead to better partner notification and an increase in CT testing and emotional support among peers [
24,
25].
Web-based CT care programs focus on utilising the factors identified as facilitators for CT testing and PN. However, factors that have been identified as barriers, especially stigma [
15,
25‐
28], may still be of concern in the processes of disclosure and encouragement. A stigma is a deeply discrediting attribute that results in widespread social disapproval [
29]. It consists of two fundamental components -- the recognition of difference, and devaluation [
30]. Stigmatization has different manifestations that can be overt (e.g., social rejection, avoidance) as well as subtle (e.g., lack of eye contact) [
29].
Public stigma refers to the cognitive, affective and behavioural responses of other people towards an individual who possesses a stigmatized characteristic. Public stigma can lead to
self-stigma which refers to an individual’s awareness of his/her stigmatized condition, the social devaluation connected with his/her condition, and the possible internalization of this stigma [
29]. Public stigma may shape anticipated stigma in persons with a stigmatized condition. However, anticipated stigma does not automatically translate into the actual experience of stigma.
Previous studies about stigma surrounding the disclosure of test behaviour have focused on anticipations or experiences with stigma by young men or women surrounding STI in general [
25], HIV [
31] and the Human Papilloma Virus [
26]. Previous research on stigma surrounding CT was conducted in a UK population with a wide age-range [
32], limiting the generalizability of the results to young populations. The present study assessed both anticipated stigma and experiences with stigma in young (16–24 years old) heterosexual men and women who had either never been tested (from here on referred to as “never tested”) or who had been tested (referred to as “tested”) for CT. By assessing the role of stigma in CT testing, disclosure of testing behaviour and encouragement of others to get tested, it is hoped that results will inform new care methods that aim to increase CT testing in high-risk groups, and thereby improve CT control.
Discussion
The present study explored the role of stigma in relation to CT testing, the disclosure of testing to peers, and the encouragement of peers to get tested, in a group of young never tested and tested heterosexual individuals.
Perceived public stigma and anticipated self-stigma were reported regardless of whether people had ever tested for CT or not. Nevertheless, all participants either intended to test when needed or had indeed tested already. This finding is in line with some other studies among tested and never tested young people in clinics, community based organizations, and household samples, where shame was not found to be a barrier to STI testing [
12,
35]. A study among young women in general practitioners settings and family planning clinics demonstrated that fear of stigmatization if they accepted screening did not lead to rejection of CT testing when it was offered to them [
36].
Tested and never tested participants disclosed both their test behaviour and, when tested, their test result to a small, trusted network of peers. They anticipated positive reactions such as support and empathy from this small network. Similar results have been found in a study among young Irish adults who informed a few “key individuals” after their testing experience, because they helped them to feel normal and gave them emotional support [
25]. Among the tested participants in this study, it was self-evident that they disclosed their CT testing and results to their sex partners, which is in line with previous studies about PN and STIs [
13]. Despite the potential self-stigma and public stigma associated with notifying sex partners, many young people consider partner notification in practice “the right thing to do”, and people’s experiences with PN were much better than they had initially expected [
13,
27,
37]. Stigmatizing reactions and shame were anticipated among all participants when disclosing details of their CT testing and results to a “non-trusted” broader network of peers. However, it has been shown that people try to minimize or regulate the negative psychological and social impact of stigma by using problem-focused and emotion-focused coping strategies [
38,
39]. In the present study, participants used selective disclosure as such stigma management strategy, and indeed no tested participants in this study had experienced stigmatizing reactions. Fear of stigmatization and the selective disclosure to a few key individuals has also been found in other studies regarding the disclosure of STI testing and test results [
25,
26], and moreover in studies investigating stigma associated with mental illnesses [
40].
Disclosure does not automatically lead to the encouragement of peers to test for CT. Novel approaches that deploy social and sexual networks in order to get high-risk individuals tested for CT place importance on pro-active encouragement among young people [
17]. Never tested participants reported that they would encourage sex partners to get tested if they themselves tested CT positive. This finding is in line with the experience of tested participants who were either encouraged by peers or who themselves had encouraged friends or sex partners to get tested. Again, stigma management strategies resulted in the encouragement only of a select trusted circle of sex partners and friends to test for CT.
In contrast to findings in other studies [
32,
41], in our study, men did not report less CT-related stigma or shame compared to women. No differences were observed between men and women regarding their stigma management strategies.
Recommendations
People do test for CT, including those who anticipate stigma. Despite anticipated stigma social and sexual networks can be reached for testing. Therefore, care strategies that deploy sexual and social networks to reach high-risk young people with CT testing are potentially effective. Yet, their effectiveness will potentially be limited by the small size of trusted networks reached due to people’s stigma management strategies. With selective disclosure and encouragement (to get tested) young people protect themselves from anticipated stigma from peers outside their trusted peer networks. Nonetheless, a person outside an individual’s trusted network may still be reached by such care strategies, because he or she may be a trusted peer in someone else’s network. Care methods, such as web-based applications that already reach high risk trusted networks, will benefit from including ways to overcome anticipated stigma without increasing the impact of experienced stigma from outside these trusted networks. For example, via anonymous disclosure and encouragement, or by the use of home-based sampling kits, which have been shown to greatly facilitate the management of sexual partners [
15,
42]. Sexual health care providers such as nurses and physicians have also an important role to play in the motivation and guidance of young people disclosing to their peers and encouraging them to get tested [
43]. Care providers are generally trained in Motivational Interviewing (MI). MI targets the intrinsic motivation of people to change behaviour by supporting people to examine and resolve ambivalence to their needs and abilities [
44]. MI is already used in PN, yet its use can be explored to reach trusted social networks but even more, to reach non-trusted networks.
Strengths and weaknesses of the present study
One of the strengths of this study is the inclusion of encouragement of peers. Several studies assessing stigma have been conducted regarding the disclosure of CT testing to sex partners and friends, but to our knowledge none of these have included encouragement of peers. A further strength of this study is the comparison between the hypothetical behaviour and anticipations among never tested young people with the real behaviour and experiences of tested young people. One possible limitation of our study is that all our tested participants were from Dutch STI clinics and all our never tested participants were from the general community (i.e., secondary school and university), and these groups might differ regarding STI knowledge and/or sexual risk behaviour. Nevertheless, we found that perceived public stigma and behavioural intentions regarding testing, disclosing and encouragement were largely similar between our tested and never tested participants. By including tested and untested young people from different backgrounds and gender, we do consider it likely that the results of this study provide a general theoretical understanding of how stigma plays a role in testing and disclosure that may be exported to provide explanatory theory for the experiences of other individuals who are in comparable situations. It is unknown whether results can be extrapolated to other target groups (i.e. men having sex with men or commercial sex workers) and to other STIs (i.e. syphilis and HIV), because of differences in sexual risk behaviour and severity of the illness, and possible related differences in anticipated stigma. Therefore, caution is warranted with regard to the generalization of these findings to other target groups than young heterosexuals and other STI than CT.
Conclusion
Young people perceive public stigma, they anticipate self-stigma and feelings of shame when they test for CT, disclose their test behaviour to peers, and encourage their peers to get tested. Nevertheless, despite these potential barriers, young people have been tested, or have expressed the intention to test for, CT. As a protection against anticipated stigmatizing reactions, people use stigma management strategies such as selective disclosure and the encouragement of only a small trusted peer network to test for CT. Care strategies that deploy the sexual and social networks of individuals can reach into small networks surrounding a person. These strategies could be improved by exploring methods to reach high-risk network members outside the small trusted circle of a young person.
Key messages
-
Young people perceive public stigma with Chlamydia testing
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Despite feelings of shame and anticipated self-stigma, young people would be willing to test for Chlamydia
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Stigma surrounding disclosure of testing behaviour and encouragement of others to test is anticipated. However the experience of stigma is effectively avoided by only disclosing to a small trusted peer group.
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Young people use stigma management strategies such as selective disclosure and selective encouragement of trusted others to protect themselves from stigmatizing reactions
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Care strategies that deploy social and sexual networks to invite young people to test for Chlamydia need to take into account the small size of these trusted peer networks.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ST and KT carried out the study, participated in the design of the study, performed the analyses, and drafted the manuscript. CH, RC, GK, AB and NDM participated in the design of the study, discussed the interpretation of results, and helped draft the manuscript. All authors read and approved the final manuscript.