Objectives We aimed to investigate how an infection with Chlamydia trachomatis (CT) influenced patients’ well-being and whether there were differences due to gender, age or relationship status, in an effort to strengthen preventive measures and provide better healthcare for patients with CT.
Methods Patients diagnosed with CT in the county of Västerbotten, Sweden, were asked to fill out a questionnaire about their feelings, thoughts and actions after CT diagnosis. The patients were also asked to fill in the validated questionnaires Hospital Anxiety and Depression Scale and Alcohol Use Disorder Identification Test. Between February 2015 and January 2017, 128 patients (74 women and 54 men) were included in the study.
Results After being diagnosed with CT, men were generally less worried than women (P<0.001). Women worried more about not being able to have children (P<0.001) and about having other STIs (P=0.001) than men did. Men felt less angry (P=0.001), less bad (P<0.001), less dirty (P<0.001) and less embarrassed (P=0.011) than women did. Nineteen per cent of men and 48% of women reported symptoms of anxiety. The majority of both men (60%) and women (72%) had a risk consumption of alcohol.
Conclusion Women and men reacted differently when diagnosed with CT. Women worried more about complications and more often blamed themselves for being infected. Being aware of these gender differences may be important when planning preventive measures and during counselling of CT-infected patients. Persons working with patients with CT must also be aware of the high frequency of harmful alcohol consumption among their patients.
- chlamydia infection
- sexual health
- chlamydia trachomatis
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Chlamydia trachomatis (CT) is the most common bacterial STI and also the most common notifiable infection in the European Union and the USA.1 In Sweden, the CT infection rate has been increasing for many years but is now stable at around 38 000 reported cases per year. The WHO has estimated the worldwide incidence of CT to more than 100 million cases per year.2
CT infection is a substantial burden for the individual and for the society, costing around US$700 million per year in the USA.3 Ascending CT infection may cause pelvic inflammatory disease with subsequent adhesions and obstruction of the fallopian tubes, causing tubal factor infertility and ectopic pregnancy.4 Complications due to CT may be much more common than previously expected and the frequency among hospital inpatients underestimated.5
In Sweden, testing and treating for CT are free of charge, and the patient is obliged by law to participate in contact tracing and not spreading the infection.
Sexual habits and attitudes have changed within the last decade, and the number of lifetime partners, unprotected sex and sex at first date is increasing.6 In a previous study, we showed that condom use was low and that correct condom use was even lower. Only 5% in the study used a condom during the entire intercourse.7
Risk factors for acquiring a CT infection include young age,8 multiple sex partners within the last year,9 not using a condom consistently,10 high alcohol consumption11 and previous CT infection.12 While there is much knowledge about CT risk factors and complications, whether the diagnosis has any impact on patients’ psychological and sexual health is less studied. CT screening in itself was associated with reduced anxiety in a previous study,13 while in another study youths perceived public stigma and anticipated shame and stigma in relation to CT testing.14 This was reported no less by men than women, which contrasts another quantitative study where women in particular described stigma in relation to CT diagnosis.15 A study of coping mechanisms in patients with CT or gonorrhoea infection indicated that denial was associated with baseline depressive symptoms, while problem-focused coping was associated with more consistent condom use at follow-up.16
In the present study, we aimed to investigate how an infection with CT influenced patients’ well-being and whether there were differences due to gender, age or relationship status, in an effort to strengthen preventive measures and provide better healthcare for patients with CT.
Materials and methods
Patients attending the STI clinic at the University Hospital in Umeå, Sweden, who were diagnosed with CT infection, treated and referred to our counsellor for contact tracing, were consecutively included from February 2015 to January 2017. There was a break during July 2016 due to holidays. During the study period, 166 patients with CT met the counsellor for contact tracing. Eighteen patients were not asked to participate because of language difficulties or because of lack of time. Twenty patients were asked to participate, but declined, most of them due to lack of time and some of them simply because they did not want to. A total of 128 patients were included in the study (table 1), 74 women aged 18–45 years (mean age 24 years) and 54 men aged 17–37 years (mean age 25 years). Forty-seven men (87%) and 67 women (88%) completed the Hospital Anxiety and Depression Scale (HADS) and Alcohol Use Disorder Identification Test (AUDIT) questionnaires.
In the county of Västerbotten contact tracing is centralised due to better results by specialised tracers.17 The diagnosis of CT was made with nucleic acid amplification test, from urinary samples in men and in the beginning of the study by urinary samples combined with self-taken vaginal swabs, and from 1 April 2015 by vaginal swabs only in women (Cobas, Roche Molecular Systems, Branchburg, NJ, USA). Tests were analysed by the Department of Microbiology, University Hospital, Umeå. Patients were informed regarding test results and treated with doxycycline, 100 mg, two tablets on day 1, and one tablet daily for another 8 days, according to Swedish praxis. Most patients were treated at our STI clinic and a few were treated elsewhere, mainly by their general practitioners. After informed consent the patients were asked to fill in three questionnaires. The only exclusion criterion was not mastering Swedish well enough to answer the questionnaires. A symptoms questionnaire included questions about their feelings, thoughts and actions after being informed that they had a CT infection (table 1 and table 2). The patients, except for the first 14, were also asked to fill in the validated questionnaires HADS and AUDIT.
This questionnaire was developed by us and thoroughly reviewed by senior consultants in the department, although not formally validated. Questions were graded 1–5, where 5 meant fully agree, 1 not at all and 3 neutral. There were 20 questions for everyone to answer. The answers were analysed with regard to differences due to gender, age and relationship status (table 1). Age of 23 years was set as a divider since that is when patients no longer can visit the youth centre. Six more questions were asked to those in a relationship about how the diagnosis had affected the relationship (table 2). In some questions there were missing answers, and those were excluded from the analysis of that specific questions. The maximum number of missing answers to any question was five.
In addition, we applied the well-validated and common HADS and AUDIT questionnaires.
Hospital Anxiety and Depression Scale
The HADS questionnaire is intended for use in somatic and primary care and contains 14 statements, each with four answer alternatives.18 Seven statements measure anxiety and seven measure depression. The answer alternatives are given values from 0 to 3; hence, the total score ranges from 0 to 21 in the respective areas. A total score of >7 indicates symptoms of mental disorder. A score of more than 10 points indicates clinically significant depression or anxiety. HADS has been validated in an STI clinic population. In the validation, a cut-off of >7 gave the best balance of sensitivity (82% for depression and 70% for anxiety) and specificity (94% and 68%, respectively).19
Alcohol Use Disorder Identification Test
The AUDIT questionnaire is aimed at early identification of people with hazardous alcohol consumption. The questionnaire has been compiled by a group within the WHO and is a standard test in a number of countries.20 21 The questionnaire consists of 10 questions, with three or five answer alternatives per question. The answers are given values between 0 and 4 for each question, giving a total score ranging between 0 and 40 points. The cut-off point used for risk consumption is ≥6 points for women and ≥8 points for men. The cut-off point indicating harmful consumption is ≥14 points for women and ≥16 for men.22
The Χ2 test was used for comparison of proportions, that is, comparing prevalence between groups. For comparisons between groups regarding mean questionnaire results of specific questions, the Mann-Whitney U test was applied, since data were not normally distributed. A P value of 0.05 or less was considered statistically significant. All statistical analyses were performed using SPSS V.23.0.
After being diagnosed with CT women talked to their friends more than men did (mean score 3.7 vs 2.9, P=0.006; table 1) and more often felt like they did not take care of themselves (3.0 vs 2.1, P<0.001). Men were, compared with women, less worried since CT is treatable (4.0 vs 3.1, P<0.001) and less worried that the infection would not heal (1.9 vs 2.4, P=0.021). Women worried more about not being able to have children (3.1 vs 2.0, P<0.001) and about having other STIs (3.0 vs 2.1, P=0.001) than men did. Women also felt more guilt about possibly having infected someone else (3.4 vs 2.9, P=0.037) and reported not being particularly proud of their actions (3.5 vs 3.0, P=0.040) in greater extent than men did. Men felt less angry (1.7 vs 2.5, P=0.001), less bad (1.8 vs 2.7, P<0.001), less dirty (2.0 vs 2.9, P<0.001) and less embarrassed (2.4 vs 3.1, P=0.011) than women did. There were no statistically significant differences between women and men in the effects on the relationship for those with a partner (table 2).
Patients ≤23 years worried significantly more often about not being able to have children (2.9 vs 2.3, P=0.014) and felt angrier (2.5 vs 1.9, P=0.002) than patients >23 years. The younger patients more often reported that the CT infection did not change the way their friends saw them (4.5 vs 3.8, P=0.004; table 1). There were no statistically significant age differences in the effects on the relationship for those with a partner (table 2).
There were no statistically significant differences in answers between those who were engaged in a relationship compared with those who were not (table 1).
Anxiety and depression
Nine men (19%) vs 32 women (48%) (P=0.001) reported symptoms of anxiety (>7 points). Four men (8.5%) vs 21 women (31%) (P=0.002) reported clinically significant anxiety (>10 points). Four men (8.5%) and six women (9.0%) reported symptoms of depression (>7 points). Two men (4.3%) and three women (4.5%) reported clinically significant depression (>10 points). Three men (6.4%) and six women (9.0%) had symptoms of both anxiety and depression.
Forty-seven men (87%) and 67 women (88%) completed the AUDIT questionnaire. Twenty-eight men (60%) vs 48 women (72%) (P=0.047) were risk consumers of alcohol (≥6 points for women and ≥8 points for men). Four men (8.5%) and one woman (1.5%) reported harmful consumption (≥14 points for women and ≥16 points for men).
Risk consumers of alcohol had a 70% increased risk of anxiety, although this correlation was not statistically significant.
Our study showed several significant gender differences regarding the experience of acquiring a CT infection. Women had a higher score regarding subjects about health and the possible interference with fertility, while men were less worried and were more satisfied because treatment is available. Knowledge about how CT-infected women and men might think and feel could help health professionals in lowering the stigmatisation and anxiety levels among patients and be valuable when planning preventive strategies.
Qualitative surveys have highlighted the fact that many patients diagnosed with CT felt stigmatised.23 Knowledge of having exposed oneself to the risk of infection, unprotected contacts that one might regret, worry of being coinfected with another STI such as HIV and risk of future infertility also troubled the patients.23 24 Patients with STI have described feelings of being judged for having done ‘something stupid’, both by personnel at the reception and by other patients.24 The gender difference observed in our study may, at least partially, be due to the fact that men are not aware of the possibility that CT may also affect male fertility. It seems also as if women tend to feel ashamed, dirty and accuse themselves for acquiring the infection. Women tend to talk to their friends about what has happened, which is in agreement with the general conception that women have a stronger social network than men.25 It may be that most women know that CT may affect their possibility of future parenthood, which may explain why they feel anger as they have not taken responsibility for protection, for example, using condom. The gender differences in reactions to having a CT diagnosis might affect how patients respond to preventive measures. This is supported by a Danish study in which, after being diagnosed with CT, women were more motivated than men to use a condom more often in the future.26
Almost half of the women in our study, but only 19% of the men, reported symptoms of anxiety. These numbers can be compared with a large survey of primary healthcare patients in which 44% of women aged 18–24 years and 35% of women aged 25–34 years had symptoms of anxiety. In the same study 36% of men aged 18–24 years and 38% of men aged 25–34 years had symptoms of anxiety,27 that is, women with CT infection in our study reported anxiety symptoms somewhat more often, while men had a markedly lower result compared with primary healthcare patients. These findings are in line with previous results by others. Gottlieb et al 28 found significant increases in anxiety about sex in women with CT, while Osborn et al 29 found an anxiety prevalence of 50.3% among patients with STI in the UK in 2001, using the HADS and the same cut-off as in the present study.
With the HADS being thoroughly validated and measuring symptoms experienced during the past week, it seems unlikely that the signs of anxiety among these patients are temporary, unimportant or due to acute ‘waiting room anxiety’. Further, the associations between mental illness and risky sex are well-studied.30 ,w1 Unfortunately, our study cannot elucidate why CT-infected women have a high level of anxiety. The reason may be that the patients are anxious because of their diagnosis, in accordance with our previous findings (unpublished data from Carré H, Lindström R, Nordström A, Boman J, Janlert U, Nylander E), or that they already suffer from anxiety, leading to destructive behaviour such as unprotected sex and therefore acquiring a CT infection. To answer the question of whether anxiety or CT came first, a case–control study, a prospective study or a qualitative interview study would be better suited.
Depression, anxiety and hazardous alcohol consumption are strongly correlated.w2 ,w3 Depression and anxiety can arise from high alcohol consumption,w3 but alcohol can also moderate symptoms of impaired mental health and may be used for self-medication of anxiety and depression. Anxiety was not significantly correlated with risk consumption of alcohol in this study, but this might be due to lack of power. The high alcohol consumption can probably explain some of the anxiety burden in these patients.
Sixty per cent of men and 72% of women in this study were risk consumers of alcohol. In a public health study in Sweden, 34% of men and 25% of women aged 16–29 years had hazardous consumption of alcohol.w4 It is common to have unprotected sex and sex that one regrets during the influence of alcohol. Even if one knows the importance of safe sex while sober, this may be forgotten under the influence of alcohol.W5 W6 The very high level of hazardous alcohol consumption in this study indicates that CT preventive strategies must act on both sexual and alcohol risk behaviours.
Depression was surprisingly uncommon among our patients. Nine per cent of women and 8.5% of men had symptoms of depression. In a large survey of primary healthcare patients, 9% of women aged 18–24 years and 18% of women aged 25–34 years had symptoms of depression. In the same study 21% of men aged 18–24 years and 19% of men aged 25–34 years had symptoms of depression.27 On the other hand, the lower prevalence of depression in patients with CT seems logical since depression, by definition, lowers the power of initiative to going out and finding multiple sex partners. However, other studies of young, and often female, populations have shown an association between depression and sexual risk behaviour.w7-w9 In a population-based study, an association between STI and depression has been shown, also among women aged 35+.w10 A similar study in a resembling setting to ours found no association between depression and present CT infection.w11 Hutton et al w12 found an association between depression and sexual risk behaviour, defined as prostitution, sex while intoxicated with drugs or alcohol, numerous sex partners, and substance or alcohol abuse. Depression was not associated to present STI or unprotected sex in that study. We believe that prostitution and substance abuse are quite unusual in our studied population, although we have no data to support this yet.
This is to the best of our knowledge the first quantitative study investigating mental health in patients diagnosed with CT in Sweden. We used well-validated questionnaires on anxiety, depression and alcohol consumption. We believe the results are valid for patients with CT in Sweden and probably also other countries with similar demographic characteristics. There are also limitations to our study, mainly the cross-sectional design, making reverse causation hard to rule out. Obtaining valid measurements on anxiety, depression and alcohol use before the infection is however limited because only a minority of the population is infected. Still, knowledge on the mental health of patient newly diagnosed with CT is rare and might be important in preventive efforts and for identifying people in need of professional support because of anxiety or depression.
In conclusion, women and men reacted differently when diagnosed with CT. Women worried more about complications such as infertility and tended to blame themselves for being infected, while men relied on the fact that the infection can be cured. Anxiety was common among female patients with CT, but our study cannot elucidate what is the cause and what is the effect of anxiety and CT. Being aware of gender differences is important when planning preventive measures regarding STI and during counselling of CT-infected patients. Persons working with patients with STI must also pay attention to the high frequency of harmful alcohol consumption among their patients and the effect alcohol has on sexual risk behaviour. Interventions to lower the alcohol consumption would decrease the sexual risk behaviour and anxiety level as well.
Little is known about psychological effects of being diagnosed with CT.
Women with CT had a higher prevalence of anxiety, worried more about complications and more often blamed themselves for being infected than men did.
Being aware of these gender differences may be important in counselling and prevention.
The authors would like to thank Kerstin Granberg Lundgren, former counsellor, and Eva-Lena Öberg, current counsellor, at the STI clinic at the University Hospital in Umeå, Sweden, for distributing and collecting questionnaires.
Handling editor Jackie A Cassell
Contributors NA performed the analyses and participated in the interpretation of the results and the drafting and revision of the manuscript. HC participated in the design and the drafting and revision of the manuscript. UJ participated in the analyses, the interpretation of the results and the revision of the manuscript. JB participated in the design and the revision of the manuscript. EN designed the study and participated in the interpretation of the results and the drafting and revision of the manuscript. All authors have read and approved the final manuscript.
Funding The study was funded by the Västerbotten County Council.
Competing interests None declared.
Ethics approval The study was approved by the local ethical review board at Umeå University (08–080M).
Provenance and peer review Not commissioned; externally peer reviewed.
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