What prompts young adults in Ireland to attend health services for STI testing?

Why do young people decide to go for STI testing?

Respondents attended health services for STI testing for one or more of four reasons. First, they had come to a transitional moment in their lives or personal relationships. This could be where respondents were about to enter a more intimate, though potentially more hazardous, phase in a sexual relationship (typically when they decided to stop using condoms for the first time) and wanted to minimize physical vulnerability and feelings of uncertainty.

I was maybe 24 and I was just moving in with a guy and we'd bought a house and we were going to be having unprotected sex and going on the pill so I said, right, I'm getting everything checked out. (F/FP/late 20 s/+).

I'm with a long term girlfriend at the moment and we don't want to use condoms any more and she got tested and I got tested. We wanted to be sure that we were both clean and that we wouldn't be giving anything to each other. (M/SH/early20 s/-).

A transitional moment could also be an instance where respondents were emerging from a sexually risky phase of their lives. This could be a phase where respondents had had sex with a number of potentially risky partners, or when they had been in a long-term sexual relationship with a partner whom they retrospectively considered to be 'high risk'.

I was traveling abroad for a few months. I split up from my girlfriend and let myself loose being free and single again. I had a number of partners in a fairly short period of time. I felt safe. They weren't prostitutes and they weren't working in strip clubs. There's a lot of diseases with hookers and stuff like that but they were just ordinary girls that I knew from college. It was in the back of my mind that maybe there was a chance [that could get STI] so I just decided to get the test. (M/SH/mid 20 s/-).

STI testing at the exit phase of a risky relationship or life period had ritualistic and moral significance for respondents. It served to bracket the risky period/relationship and enable and mark the beginning of a new and clean identity [14], one characterized by self-respect and a protective, positive orientation towards self and body. The process of going for a STI test was portrayed as a 'cleansing' in itself.

For about a year before I had been going through a really bad time, I went out with a few different guys and stuff and just when I came through that I was kind of looking back on some of the crazy stuff that had happened in the previous year and I just wanted to completely cleanse myself of everything that had happened. I just thought, OK I suppose a part of that is going to have to be making sure that everything is OK. I don't know, I just wanted to cleanse myself of everything that had happened in that year. Just be able to close the chapter. Gone. (F/STI/mid 20 s/-).

I wasn't in a great position in my life and didn't really care too much and there was one or two times where I didn't use protection. There was a month or two where I just kind of realized the direction I was going and figured that if I wanted to make anything of my life I needed to cop myself on and start focusing on what I was doing. One part of it was to get checked out and start moving on from there. So that was what got me in the mentality of getting it done. I think that was the fundamental part of it to me. That it would help me start again. (M/SH/mid 20 s/-).

The second reason that respondents went for STI testing was that they had unprotected sex with an unknown partner.

I just had a one night stand with somebody and I didn't use protection. And I just wanted to make sure. Cos like you never know. I don't know anything about that person or, you know. (F/GP/mid 20 s/-).

I'd had unprotected sex and just thought I should get checked. I didn't have any symptoms but I still kind of worried about it. (M/SH/early 20 s/-).

Respondents (especially female respondents) typically experienced unprotected sex with an unknown partner as a catastrophic event, triggering strong feelings of anxiety, shame and guilt. Unprotected sex undermined respondents' identities, their sense of who they were as individuals. One respondent for example noted:

I just did this [had unprotected sex], my God, what kind of person am I? (F/GP/early 20 s/-).

Unprotected sex catapulted several respondents into a state of vulnerability, triggered by uncertainty over the body's risk status.

I was quite nervous cos like you don't know. I wasn't sure like, had I got anything, had I not got anything. Any other times I've gone since I've known I've been safe but that time because I knew I'd had unprotected sex I was quite unnerved by the fact that I could have something. (Female/GP/early 20 s/-).

STI testing provided emotional reassurance, and a means of stitching a 'respectable' identity back together by enabling respondents to feel that they were risk-avoiding responsible individuals who looked after their bodies.

Interviewer: And how did you feel about yourself after you had the test?

R: Better. Like I was someone who had done something right (F/GP/early 20 s/-).

The third reason for going for testing was the presence of unusual symptoms in or near the genital region. Respondents were often unsure of what these symptoms were, and sometimes did not expect them to be symptoms of an STI. As such these respondents did not necessarily attend health services for STI testing. Most of the symptoms that respondents reported were described as being 'marks' or 'spots'. Symptoms that would indicate discharge from the vagina or penis were rarely mentioned.

I kind of had a mark down there and I was unsure of it you know. (M/GP/late 20 s/-).

My background would have been that it was symptoms in the genital area so that's why I decided. I hadn't a clue. (F/STI/late 20 s/+)

Obviously they came up like spots down there. I got sore and red. I actually didn't think it was going to be an STI. I'd never really heard about them. I thought it was just a rash so I said it to my sister and my mum not really thinking much about it. (F/GP/early 20 s/+).

I had symptoms that I would attribute to an STI like increased frequency of weeing or stuff like that. (F/SH/late teens/+).

The final reason for attending a health service for STI testing was being required to by an employer or by a state. Of the four reasons provided here for attending a health service for STI testing this was the most meaningless for respondents, as it was the most disconnected from their personal practices, biographies and emotions.

I just went into the doctor and I said I need a visa for working abroad, can you give me a HIV test. I didn't see that test as having any personal significance. It was just a piece of paper that I needed. (F/STI/mid 20 s/-).

Most respondents who sought testing wanted to receive a 'full screen', that is to be tested for all of the most common sexually transmitted infections. As noted in the next section, several respondents were particularly concerned about being tested for specific sexually transmitted infections such as Chlamydia (the young gay men who took part in the study (n = 3) were the only respondents to be concerned about Syphilis, and were the most concerned about contracting HIV); however these respondents, too, wanted 'full screens'. Respondents themselves (prior to completing testing) were often unsure about all of the STIs that they could be tested for. Analysis of interview transcripts reveals that most respondents were tested for HIV/AIDS, Gonorrhea, Genital Warts, Herpes, Non-Specific Urethritis (NSU), Chlamydia, Syphilis, Hepatitis and Trichomonas. Respondents who tested positive for STIs were all diagnosed with Herpes, Chlamydia or NSU.

Factors encouraging testing

Several factors encouraged respondents' decision to seek STI testing. One was seeing STI testing as a responsible practice that adults should engage in.

I'm nearly 28. I think it's just kind of the mature thing to do. (F/STI/late 20 s/-).

I'm a grown up. It wasn't something I would have even thought of when I was younger. (F/FP/late 20 s/+).

Another was having a protective orientation towards partners and other young adults. All respondents' indicated that they would experience significant guilt and distress if they transmitted an STI to another individual. STI transmission was viewed as a fundamentally unjust activity, a violation of moral norms.

I'd feel like shit, absolutely [if I passed on a STI]. And that's why I wanted to get screened as well. I didn't want to do that cos I've had sexual partners in the past and she hadn't. I suppose it's like a domino effect, it's like passing it onto somebody and they in turn pass it on to somebody else. It's kind of unfair. (M/SH/early 20 s/-).

Respondents (male and female) expressed particular concerns about the damage that STIs could do to their future fertility, indicating awareness of important complications in this at-risk group. STI testing was seen a crucial means of protecting this fertility.

I just wanted to make sure I didn't have anything. I got a full testing like. Just for peace of mind. I could end up not being able to have children or like, I don't know, getting someone else not able to have to children (F/FP/late teens/-).

The perceived risk status of respondents' sexual partners was also a factor that influenced care-seeking. Respondents judged partner's risk based on a number of characteristics, including appearance and geographical origin. As such they sometimes tended to rely on visual cues when judging partners' risk status. 'Dirty' partners or those from perceived risky regions (especially Africa and South America) were most likely to increase respondents' concerns about the need to seek STI testing. Partner's past sexual history also influenced their care-seeking behavior; however in many cases respondents had only a vague notion of their partner's actual sexual history other than that it had been 'colourful'.

If they had AIDS or herpes I presume I would have noticed something. But this one was so random and drunken and stupid. And I don't know the guy, he was from Africa. I know that's an awful preconception but if he didn't want to use a condom with me I presume he didn't use one with anyone else. (F/GP/early 20 s/-).

I possibly didn't know as much about his partners or how many there might have been. (F/GP/mid 20 s/-).

Many respondents who did not have symptoms when they attended health services testing expressed anxieties about the risk that asymptomatic STIs (especially Chlamydia) could affect them without their knowledge.

I've heard that there's no symptoms with Chlamydia and I've no symptoms so I thought that maybe if I do have one, this could be it (M/SH/early 20 s/-).

Chlamydia is such a scary, scary thing now, cos it's you know asymptomatic (F/GP/late 20 s/-).

Respondents' anxieties about symptomless STIs stemmed from two sources. The first of these was consciousness-raising health promotion materials.

I remember at the time they were doing a thing on Hollyoaks [British soap opera for young adults]. They were doing the whole STI thing on the TV. It was basically what I got from there. (F/GP/late 20 s/+).

You are aware, you see the signs around and advertising on TV and you are aware that unprotected sex is not entirely beneficial for you! And the risk of catching an STI is quite a real risk nowadays (F/GP early 20 s/-).

The second was proximity to individuals who had been diagnosed with STIs.

And I know a girl who had it at one stage so. When someone in your circle of friends has had it you're thinking well like maybe it's more common than a lot of people think. That was the only reason I was thinking it. (M/SH/early 20 s/-).

Just that somebody close to me had done it and it was grand. It kind of brought it more down to earth rather than something that gets done. You know what I mean like. It was always there, this STI check but now somebody had actually gone for it in DIT as well, so it was close by. It was more real than something I just saw on a poster. (M/SH/early 20 s/-).

Together health promotion materials and contact with individuals who had attended for STI testing appeared to disrupt what sociologist Anthony Giddens [15] referred to as respondents' 'protective cocoons', the psychological filters that they used to screen out threatening anxieties. These included thoughts that they could have, or might be at risk of having, STIs, and which they used to maintain feelings of invulnerability and 'personal specialness'. Health promotion and by-proxy awareness of STIs interfered with the psychologically protective delusions that respondents might otherwise have had about STIs, such as 'only 'bad' people get STIs' and 'the chance of contracting an STI is miniscule'. They revealed to respondents that many people contracted STIs, including people 'like them'.

Delayed testing

A number of respondents immediately followed through on their decision to go for testing. The feature that all of these respondents had in common was an immediate, pressing anxiety to know if something was wrong with their bodies. This stemmed from a perceived high risk that they could have an STI.

I kissed a fella who had syphilis. I was like to him, I'm not being bad but I have to get checked now (M/MSM/late 20 s/-).

I had to find out what it [symptom] was. (M/GP/late20/-).

Most respondents, though, delayed to varying extents on following through on their decision to attend a health service for STI testing. This'procrastination period could last from several weeks to, in one instance, over seven years. Anxieties about the potential social consequences of being diagnosed with an STI were common reasons for delay. Respondents felt that STIs were highly stigmatised infections in Ireland and that even being known to attend a health service for testing could discredit young adults' identities.

People are afraid of the consequences of what's going to happen if you do have this thing. (F/FP/late 20 s/+).

Feelings of shame and embarrassment encouraged delay. These feelings could be associated with the STI testing process, such as having to take clothes off in front of healthcare professionals (this concern was much stronger amongst female respondents).

The reason I hadn't gone before was because of plain mortification. Because of stripping off for the doctor or whatever and it's a bit embarrassing really. (F/FP/late 20 s/-).

They could also stem from respondents' original reasons for going for testing. For example, respondents who wanted to go for testing because they had had unprotected sex, and were ashamed about this, were often concerned that their healthcare provider would judge them and their behaviour as 'shameful'.

Respondents without symptoms often indicated that while testing was a positive practice to engage in, it was not an urgent one.

I went about a year later. There wasn't any cause for concern. There was nothing obvious happening. (M/SH/early 20 s/+).

Lack of urgency here was connected to feelings of invulnerability, feelings that the individual could not really be at risk if everything appeared to be functioning normally.

I would have had unprotected sex with men before but I just assumed I was fine. I presumed it was perfect, I was grand. This kind of immortality vibe, you're grand, you're healthy, everything is fine. (F/FP/late 20 s/+).

The cost of attending a health service for STI testing could also discourage respondents from seeking immediate help.

I mean you could go to your GP and maybe get something done quicker but I went to the clinic where it was free because I couldn't afford to pay whatever to your GP like 50 or 60 euro to see him on top of whatever it costs to get those tests done. (F/STI/late 20 s-).

Several respondents from poorer areas noted that they needed to spend several weeks saving up enough money to pay for their STI tests. In Ireland individuals whose income falls below a certain level can apply for 'medical cards', which entitle them to free healthcare at their local GP practices. Respondents from poorer backgrounds who had these cards, however, often did not want to seek treatment from their local GP because of concerns that they would be judged by him or her as being promiscuous or immoral. As such they sometimes sought treatment at practices or centers where they had to pay for treatment but where they would be unlikely to encounter a healthcare professional who could judge them.

Respondent: I needed to save up the money. It was like 150 euro. I didn't have the money straight away. I got it about a month after that.

Interviewer: Was it difficult to get the money together?

R: Yeah. Cos it was 150 euro because I got a full test.

I: So how did you get the money together.

R: Working. I work like.

I: Did you have to give up stuff.

R: Yeah, it was hard. It was just hard to keep all my money and not spend money. (F/FP/late teens-).

Preferences for attending clinics that were further away from where respondents lived or worked and which were subsequently more difficult to attend were more likely to lead to procrastination behaviors. Clinic opening hours – especially for STI clinics – could also lead to delayed attendance. Respondents who attended these clinics did so for two principle reasons: the clinics were free and they were thought to have expertise in treating STIs. The demand placed on these clinics was such, however, that respondents often faced difficulties accessing them, which further delayed testing.

I was told to be at the clinic 90 minutes before they started testing at 1 pm but I was there an hour early. They'd given out all the tickets at 11.30 am so I was too late. I then asked about the the other hospital clinic and was told about the six week wait. (Male/MSM/late 20 s/-).

Interestingly, some respondents who delayed testing (for reasons unrelated to difficulties accessing clinics because of long-waiting times) did not view themselves as delaying. These respondents appeared to have an elastic conception of what immediacy was in relation to STI-related health-seeking.

Respondent: I went straight away [for test].

Interviewer: And how long was that?

I: I think within four weeks (F/SH/early 20 s/-).

Re-testing

A minority of respondents (all either women or MSM) attended health services for re-testing. There were four reasons why respondents went for re-tsting. One was to receive a test of cure in the event that they had tested positive for an STI.

They do advise after you've had a course of meds and taken them properly, to go back after six months and have another check. It's all free of charge. (F/GP/late 20 s/+).

The second was to manage any uncertainty remaining from the first test. Uncertainty related to the STI status of the body (whether the individual was positive or negative) and could develop because the individual had not successfully completed his or her course of medication or because her health service had not contacted her to tell her that her results were either positive or negative.

I was wanting to [get re-tested]. I think because I'd been nearly caught, until I'd got the all clear again I wasn't happy. It was more a thing that I needed to do for myself. I was happier once we'd had the all clear. I just needed to get it right in my own mind. (F/GP/late/+).

I needed to see it in black and white 12 months later that it was clear on both of our parts. I think it's just a psychological thing. (F/GP/late 20 s/+).

The third reason related to the cleansing nature of STI testing. Some respondents experienced STI testing as a moral practice (using words like it was the 'right' thing to do, a 'good' thing to do) and received positive feedback from their (negative) test results, which encouraged them to seek further testing in future.

I'm just addicted I think to getting checked. Even though I know I don't have anything it's just nice to know I'm after getting it done again and I'm still clean. (M/MSM/late 20 s/-).

The fourth reason was relevant to re-testers who had tested positive in their first test. Testing positive damaged these respondents' protective cocoons, the psychological filters that they used to screen out risk anxieties; as such they perceived themselves as being more vulnerable to risk than other respondents. STI re-testing, as well as being a course of action that was sometimes advised by the health provider, provided respondents' with a mechanism to manage risk, acting as a psychological 'protective shield' against feelings of vulnerability. Re-testing also had the advantage of enabling these respondents to test their partners' faithfulness, and whether they could continue to trust them or not.

Generally, re-testers found re-testing to be a more positive experience than the initial testing experience. Re-testers had experience of the most effective procedures to use to access particular healthcare settings (for example, knowing to queue early to get into an STI clinic) and their concerns about stigma and being judged had often been positively addressed by healthcare professionals on the first visit.

I just kind of knew what to expect. I had the feelings before so they weren't fresh. They didn't stick in my mind. It's not that it was fine, it was still. It was just a more comfortable experience because I knew what to expect. I knew what was happening. (F/GP/mid 20 s/-).

I would say that it's much easier since I've got it done. It's still, taking off your clothes and stuff like that, a very intimate procedure but the first one is definitely the hardest. (F/FP/late 20/+).

One re-tester's identity concerns became more acute the more she attended health services for testing, however. She felt that regular re-testing signaled to healthcare workers that she was being continuously promiscuous, sleeping with many different risky men on an on-going basis. As such the act of re-testing risked stigmatizing and spoiling her identity more than the original act of testing did.

You know if you change partners then it's like I'm being really bold. It's the whole slut factor again you know. Six months later you have another new partner and you go in for another screening and then it's again the whole what are they going to think of me. (F/GP/late 20 s/-).