Triggers of self-conscious emotions in the sexually transmitted infection testing process

Sexually transmitted infections (STIs) are public health priorities because of their associated risks, such as infertility, ectopic pregnancy and pelvic inflammatory disease [1–3]. Early detection and treatment of STIs is important so as to shorten STI infection duration, which in turn determines the risk of transmission of STIs to partners and the severity of sequelae [4].

Emotions such as embarrassment, shame and guilt play important roles in influencing individuals' decisions to seek treatment for suspected STIs, and also their experiences of attending sexual health services if they choose to act on these decisions [5]. These emotions can act as significant barriers to accessing appropriate healthcare advice and treatment [5, 6]. Research has shown that individuals can feel embarrassed looking at information about STI testing, which can put them off reading and following through on this information [7, 8].

Embarrassment is commonly experienced by young people who talk to healthcare providers about their sexual behavior, and can result in them failing to request STI testing [9, 10]. Young people can even feel ashamed just anticipating talking to a health professional about these matters [11]. Individuals often feel ashamed about being witnessed (or thinking that they might be witnessed) visiting STI clinics, which can discourage them from attending these services [12]. Being offered opportunistic screening by professionals in public areas (such as at reception desks) can be 'excuciatingly embarrassing' for some young people [13].

Those who do decide to seek STI testing often struggle to manage these feelings and may drop out of the STI testing process if they cannot do so [14]. A positive diagnosis of an STI can trigger intense negative affect [15]. These emotions can prevent young people from discussing their STI status with their past, present or future partners. This in turn increases these partners' risks of developing STI-related sequelae if they, too, are infected [9, 16]. Individuals who choose to hide their positive STI status from their partners, however, often feel guilty about doing so [15].

Overall, the studies mentioned here have demonstrated that emotions such as embarrassment, shame and guilt are part of many people's experiences of seeking STI care. These feelings are deeply unpleasant to experience and individuals who seek STI testing are motivated to avoid them [8, 10], even though this can have negative impacts upon their health. Consequently, researchers [8, 17] have called for more work to be undertaken on the connections between shame, guilt, embarrassment and sexual behaviors, including STI testing.

In this article we explore and identify the specific events in the STI testing process that trigger emotions such as shame, embarrassment and guilt in young adults who seek STI testing; and seek to understand what it is about these events that triggers these emotions. Being able to identify specific emotion inducing-incidents and components of the STI management process should enable service managers and practitioners to design sexual health services that decrease the likelihood that patients will experience distressing emotions during their testing experience and that will consequently increase service uptake, especially among young adults who are at most risk.

The emotions of embarrassment, shame and guilt share substantial features in common [8], such that researchers have argued that they form a single family of negative emotions- the self-conscious emotions. These emotions are labeled self-conscious because individuals' understandings and evaluations of their own selves, and their awareness of the selves of others, are crucial to their formation [17]. Self-conscious emotions develop when individuals' skills, competencies or characteristics are called into question or transgress relevant social standards [18], and when individuals believe that others will negatively view their failures or violations. This latter point is crucial - individuals experience self-conscious emotions not as a result of how they view themselves, but from how they think others view them; from imagining how they are viewed through the eyes of other people [18]. 'Others' can be real people, or they can be internalized standards or behavioral reference points (e.g. images of how a person is 'supposed' to behave in a particular situation) against which the person compares her own practices.

Though most self-conscious emotions are unpleasant to experience, they have important social functions [8]. For example, they help to keep behavior within acceptable social limits [19]. The negative flavors of these emotions mean that once individuals are given a taste of them, they are usually motivated to avoid situations that give rise to these emotions in the future [17]. Self-conscious emotions can also act as behavioral flags, indicating to a person instances where she is not living up to expected standards; they thereby provide the person with important feedback on her thoughts and practices as these could be viewed by others [8].

There are different types of self-conscious emotions. Shame, or self-disgust [19], is a negative emotion characterized by intense discomfort, feelings of exposure, inadequacy and worthlessness, and a desire to hide. It develops when an individual fails in relation to some personal or social standard, feels this failure to be a representative symptom of a globally defective self or identity [5] and believes that others will appraise this failure negatively [19]. Common triggers of shame include poor-performance and role-inappropriate behavior [19]. Shame is associated with a desire to undo or destroy those aspects of the self that give rise to it. Tantam [19] notes that many people will go out of their way to avoid situations where they could be shamed, because these feelings are almost like dying or being annihilated.

Guilt is an emotion that is similar to shame, though it arises in response to a specific undesirable behavior rather than in response to an undesirable self [20]. Unlike shame, situations that produce guilt do not tend to call individuals' entire selves into question. And whereas shame induces a desire to run and hide from others, guilt encourages the individual to move towards others in order to make reparations for the behavior that caused the guilty feeling in the first place.

Embarrassment, according to Miller [21], is a self-conscious emotion characterized by flustered abashment and chagrin stemming from events that increase the threat of unwanted evaluations from real or imagined audiences. As with guilt and shame, the crux of embarrassment is negative evaluation by real or imagined others [8]. Embarrassment develops when individuals believe that others have formed an undesirable impression of them because they have violated norms of demeanor, good manners, self-control or bearing [21, 22]. As with guilt, though unlike shame, embarrassment is likely to develop in relation to a characteristic that an individual does not believe to be representative of her core identity. In general, individuals are less likely to become embarrassed around people they know well, because they are more certain that these people will not negatively assess them.

Self-conscious emotions are often triggered by self-presentational failings [8]. Self-presentation refers to the tactics and strategies that individuals use to control how others perceive and evaluate them [8]. By engaging in self-presentational activities individuals can construct and maintain positive social identities and can claim 'face' [8], or social worth and respect. Individuals will usually attempt to present images of themselves that are consistent with the norms that are relevant to particular social settings and with the general social roles that they occupy [18]. When individuals' execute their self-presentational activities in a flawed manner, however, for example by doing something that undermines an image of competence, or when they engage in role inappropriate behavior that is witnessed by others, self-conscious emotions can be triggered. Individuals are generally motivated to avoid potential situations that could lead to self-presentational failures and consequently generate feelings such as shame, guilt or embarrassment.

Thirty semi-structured interviews were conducted with young adults who had previously attended health services for STI testing in the Republic of Ireland. Respondents were recruited from three General Practice (GP) practices (one urban middle-class GP practice, one urban working class GP practice and one rural GP practice), one Third Level College health service, two Family Planning clinics (one serving an urban middle-class population and the other serving an urban working class clientele) and a specialist STI treatment service for men who have sex with men (MSM). We utilized a qualitative approach because we wanted to explore young people's perspectives in detail. Qualitative methods have proven efficacy in sexual health research [23].

Respondents were eligible to take part in the study if they were between eighteen and twenty nine years of age (the age group with the greatest increase in detected incidence of STIs in the Republic of Ireland over the previous decade) [24]. We purposely sampled respondents in order to recruit both men and women, respondents of different ages (late teens, early 20 s, mid 20 s, late 20s), and respondents who had sought STI testing from specialist and community-healthcare settings. Twenty one respondents were female, nine were male. Three respondents (recruited from a specialist urban health clinic for gay men) self-identified themselves as being gay. The other twenty-seven respondents self-identified themselves as being heterosexual. We did not ask respondents to self-identify their class backgrounds, though seven respondents were recruited from urban working class settings, ten from urban middle-class settings, five from the college health service and five from the rural GP setting (which also served a primarily middle-class population). Approximately 33% of potential respondents whom we approached agreed to take part in the study (we handed out 110 recruitment leaflets to potential respondents, of whom 30 agreed to be interviewed). Ethical approval for the study was received from the authors' institutional ethics committee and from the ethics committee of the Irish College of General Practitioners.

Respondents were recruited either by the first author or by a healthcare professional working in the healthcare setting that respondents were attending for STI testing. Potential respondents were provided with an information leaflet, which provided background information on the study, what participation in the study would involve (up to one hour interview focusing on respondents' experiences of attending services for STI testing); respondents' freedom to avoid issues and stop the interview at any point; and assurances on anonymity and how information would be recorded and used. Participating respondents were asked to respond 'yes' by text if they were interested in taking part in the study and were given the option of completing their interview by telephone or face-to-face. Twenty four respondents chose to do their interview by phone and six face-to-face. Respondents who completed face-to-face interviews were asked to provide written consent to take part in the study. Telephone interviewees were asked for verbal consent to take part. Telephone interviewees were asked over the phone if they wished to take part in the study, and were reminded about guarantees around anonymity and data storage. They were informed about the overall purpose of the study and were asked to provide verbal consent if they wished to take part in it. Respondents were informed that they could stop their telephone interview at any point, and that they did not have to answer any questions that they did not wish to. They were also asked if they had any questions about the project. Once the interview began respondents were put on loudspeaker on the first author's office telephone and the interview was recorded with a digital voice-recorder (approval to record the interview was sought before the interview began). When the interview had finished the voice-recorder was turned off and respondents were asked for their home address. The interviewer posted respondents gift vouchers to this address and then deleted the address.

The first author, a Ph.D. sociologist specializing in qualitative methods, interviewed respondents. A semi-structured interview approach was used for both face-to-face and telephone interviews. Interview questions examined respondents' experiences of seeking STI-testing and specific events in the STI-testing process that respondents especially liked or disliked (and why). Follow-up questions explored the reasoning behind respondents' responses in more detail. A non-directive approach was used in the interviews to allow respondents to shape their own accounts. Interviewing continued until we deemed data saturation to have been reached (the point at which no new themes were emerging). Researchers have proposed 30 as an approximate or working number of interviews at which one could expect to be reaching theoretical saturation when using a semi-structured interview approach [25].

Interviews were tape-recorded (with respondents' permission) and fully transcribed by a medical secretary. To check the accuracy of the transcripts both authors re-listened to the interview recordings of the first three interviews while reading the transcripts of those interviews; subsequent transcripts were read without reference to the original audio recordings. Both authors were involved in coding and analyzing all of the transcripts. The analysis process was as follows: significant key words, phrases and themes in the interviews were marked with summary words or codes. As each transcript was coded, all codes that were thematically similar were grouped together, and labeled with a summary code, called a category. In line with standard qualitative procedures, these categories then became the organizing themes of our analysis. Categories related to instances in the STI testing process that triggered self-conscious emotions for respondents. Categories were not pre-determined but emerged during analysis. For example, when we began the study we had a fairly open-ended objective: to examine the barriers that prevented or discouraged young adults in Ireland from seeking STI-testing. It was only when we began conducting the interviews, and particularly when we began analyzing them, that we saw the central role played by self-conscious emotions (particularly shame and embarrassment) in respondents' experiences. In situations where discrepancies were detected between codes the procedure was for both authors to meet to discuss these discrepancies; and to discuss whether or not the discrepancy existed because codes addressed different aspects of respondents' experiences (i.e. different events in the STI testing process) or because we had not yet constructed a sufficiently abstract category under which apparently different codes could be sublimated (i.e. the codes appeared to be superficially different, but were actually different 'symptoms' of the same underlying process).

This is one of only a small number of empirical studies [5, 8, 9, 27] to investigate the events that trigger self-conscious emotions in young adults who seek STI testing, although these is an increasing realization that emotional factors play important roles in young people's STI testing experiences [5]. Several of our findings are, as far as we are aware, original in terms of previous international research on this topic, including; that young people may feel more embarrassed about having to inform older partners than younger ones about the fact that they have sought STI testing; that going for STI testing with peers can reduce feelings of embarrassment for young women; that STIs that affect appearances can induce greater feelings of self-consciousness in young people than STIs that do not; that the shame associated with testing positive for an STI can negatively impact upon young people's personal identities and lead to them to engage in risky sexual practices; that some young people are concerned about informing other individuals about their STI testing practices because they believe that these individuals will not let young people process their feelings of shame and embarrassment; and that self-conscious emotions can have a particularly pernicious effect on young people whose treatment for an STI extends over a priod of time.

The relatively small sample size (30) and the fact that most of the interviews (24) were conducted over the telephone could be considered limitations, the latter because of the inability to see non-verbal responses that could guide follow-up questioning. However, by the time 30 interviews had been completed, all of the themes that had emerged were being reproduced in later interviews. Also, our experience was that the young respondents were quite comfortable with telephone interviews and that interviewing by telephone allowed respondents greater anonymity, which facilitated additional information emerging than might have been the case if the interviews had been face-to-face.

We identified seven specific triggers of self-conscious emotions in respondents' accounts and consider here their implications for the design of sexual health services for young people. The first of these relates to respondents' reasons for seeking STI testing. Having unprotected sex was the most likely factor to generate embarrassment and shame in respondents. This appeared to be because respondents who had had unprotected sex felt that their behavior violated social norms governing how sexual risk was supposed to be managed (i.e. carefully and responsibly), whereas respondents who had sought testing for other reasons did not believe that their behaviors violated these norms. Previous studies have also noted that young people can become embarrassed or feel guilty if they feel that they have engaged in (what they believe to be) careless or irresponsible sexual activities [16].

The second trigger of self-conscious emotion in respondents' accounts was having to inform peers and partners about the need to seek STI testing. Previous work has noted that young people often feel embarrassed about talking to their peers and partners about STI testing [9, 16]. The degree of embarrassment that respondents in this study anticipated experiencing was related to the perceived likelihood that they would be judged or negatively assessed by their partners or peers. It is potentially worrying that some respondents would consider not informing their partners that they had sought STI testing, for while this would protect respondents from experiencing shame or embarrassment it would increase the risk of partners suffering from STI-related sequelae if these partners had already been infected with undiagnosed STIs. We have not seen the finding been previously reported that young people might feel embarrassed about informing older partners. It is interesting, however, as it suggests that young adults who are involved in sexual relationships characterized by perceived unequal relations of power may inadvertently place their more 'powerful' partners at risk in an effort to avoid self-consciousness and threats to their identities. This also perhaps indicates a need for young people to be taught (e.g. in school) how to negotiate sexual health matters related to STI testing with partners, irrespective of these partner's ages.

The third trigger was accessing STI testing facilities. Many respondents indicated that they felt embarrassed about entering clinics and sitting in waiting areas. This was especially the case for those attending specialist STI settings. Previous research supports this finding [6, 13, 16]. What has been less commonly reported in the international literature, however, and what we found in this study, is that concerns about anticipated embarrassment influenced young adults' decisions about where to seek STI testing. Respondents' anticipated concerns were usually based on pre-conceptions rather than on previous direct experience of using clinics. We also found that bringing peers along for testing could reduce young adults' experiences of felt embarrassment while they were attending STI testing facilities (by enabling them to define the testing activity as a 'normal' rather than 'deviant' experience); we have not seen this finding previously reported.

The findings related to the third trigger firstly point to the value of delivering sexual health services, including STI testing and screening, in one-stop-shop general practice settings. Fear of stigma associated with attending a designated STI specialist clinic (be it well-founded or not) was a deterrent to seeking care for their sexual health needs for a high proportion of young people in this sample. This finding makes the case for implementing STI testing and screening in primary care settings as an additional strategy to specialist centres. Secondly, the findings point to the importance of the design of waiting areas, so as to minimize the likelihood of embarrassing interactions with others - other clients, staff and passsers-by - for those waiting to see a STI healthcare provider. Thirdly, where a range of acceptable non-stigmatizing services are made available, health promotion strategies need to communicate this to young people and could encourage them to bring a trusted peer as an active support and companion through the testing process. It is also positive to observe that efforts made by staff could help to reduce feelings of shame and embarrassment.

Discrediting interactions with healthcare professionals were a fourth trigger of self-conscious emotions. Respondents indicated that they could become ashamed and embarrassed if they felt that healthcare professionals were disparaging their identities. Negative interaction between patients and healthcare professionals is a commonly reported elicitor of self-conscious emotions in the international literature [13, 11]. Royer and Zahner [9] note that young adults can also sometimes feel embarrassed to admit to their doctor or nurse that they lack an understanding of STIs, though this finding was not reported by respondents in our study. The respondents' reports of very positive as well as quite negative experiences associated with STI providers, which were usually not determined by shared sex and age, points to the need for provider training. Where providers are unable to learn and communicate acceptance and empathy to young people effectively, they should not be considered suitable for this work.

We also found that the method that healthcare professionals used to test for STIs could induce feelings of shame and embarrassment in respondents. Other studies have also noted that young people can have strong negative emotional responses to urethral swabs and pelvic examinations [4, 13, 14]. We have not seen it previously reported, however, that young adults can sometimes experience the shame and pain generated by these testing methods as a justifiable punishment of the behavior that forced them to seek STI testing in the first place. This finding does fit with theoretical research on self-conscious emotions, though, which suggests that individuals who experience feelings of shame often want to damage or destroy the parts of themselves that gave rise to these emotions [19].

The fifth elicitor of self-conscious emotions in respondents' accounts was receiving a positive diagnosis of an STI. Respondents who tested positive for an STI often described feeling ashamed and embarrassed at the result. Previous studies have reported similar findings [16, 28, 29]. This research indicates that young adults often have negative images in their minds of the 'types' of people who contract sexually transmitted infections [12, 27]. When they contract an STI themselves, therefore, young people are forced to process the fact that their own selves may be 'defective', at least with respect to the cultural norms to which they subscribe. In contrast to previous studies, we did not find significant gender differences reported in emotions related to STIs. Royer and Zahner [9], for example, found that women often feel a greater sense of shame after being diagnosed with an STI than men do. We did find, however, greater feelings of shame and embarrassment amongst respondents who had been diagnosed with STIs that affected their appearances, such as herpes, than among those who had been diagnosed with 'invisible' STIs such as Chlamydia. This might be because visible STIs would more dramatically undermine respondents' attempts to present positive images of themselves in front of their sexual partners. One of the most interesting findings from this study was that intense shame (in this study, of the kind triggered by a positive diagnosis of an STI) can encourage (some) young people to engage in highly risky sexual practices. It is likely that this shame is driving these individuals to engage in activities that they feel will extinguish or damage 'unbearable' aspects of themselves. Though not addressed by this study, it may well be that internalized shame/homophobia encourages at least some young people risk groups such as young men in the MSM community to engage in risky/punishing sexual activities; this is an area that warrants further exploration.

The sixth trigger of shame and embarrassment in respondents' accounts was having to notify sexual partners about a positive diagnosis of an STI. Respondents often felt concerned about informing their partners about a positive diagnosis, worried that their partners would react negatively to this information. Previous studies, too, suggest that young adults can feel uncomfortable informing their sexual partners about a positive diagnosis of an STI [15, 28]. Interestingly, it was another self-conscious emotion, that is guilt, that encouraged most respondents to inform their partners when emotions such embarrassment discouraged them from doing so. Respondents were also concerned about informing their parents about positive STI diagnoses. In large part this was to avoid embarrassment, but some respondents were also worried that their parents would attempt to take ownership of their emotional experience, not allowing them the space and time to process their own feelings. We have not seen this finding previously reported in the international literature.

The seventh, and final, trigger of self-conscious emotions in respondents' accounts was seeking treatment for a positive STI. Respondents indicated that they would use a variety of 'information control' practices to protect their identities and to reduce their risk of experiencing embarrassment while they sought treatment, such as seeking treatment from a pharmacy that they would not usually attend. Previous studies, too, have found that young adults seeking STI treatment often use cover stories to hide the shame of having an STI from audience members [15]. Here, as at each of the earlier stages from the initial decision to seek information on how to access professional help, anonymity is paramount for young people.

Threaded throughout all of the triggers of self-conscious emotion identified here are concerns on the part of respondents about being judged by other people for being sexually promiscuous or for engaging in the 'wrong' role-inappropriate practices (such as having sex before marriage). Similar concerns have been identified in previous studies [28]. These studies (and this one) reveal that self-conscious emotions often emerge in the STI testing process when individuals believe (or imagine) that others have formed undesirable impressions of them [8]. In this study self-conscious emotions generally emerged when respondents felt that their social identities were under threat.

As noted previously, self-conscious emotions serve a variety of functions in individuals' daily lives, for example calling attention to important events (e.g. that an identity is under attack) and directing behavior along socially acceptable lines. The flavor of these emotions is so unpalatable that, once given a taste, individuals are usually motivated to avoid them in the future [19]. Unfortunately, although these emotions can have positive effects in the STI testing process (for example, guilt can encourage young adults to inform their sexual partners in light of a positive STI diagnosis), overall they appear to be have mainly negative effects. In order to avoid self-conscious emotions and the self-presentational failings that give rise to these emotions, young adults often engage in practices that are risky to their own health or the health of their sexual partners, such as refusing to inform their partners that they are thinking of seeking STI testing [8].

Finally, one of the interesting findings to emerge from this study was the relative homogeneity that existed between respondents in terms of the items that triggered self-conscious emotions in them (though the degree of the self-consciousness that particular respondents associated with particular triggers could vary), irrespective of whether or not they were male or female. Nevertheless, respondents did differ along a variety of dimensions. Respondents differed in relation to: their rationale for seeking STI testing (respondents who did not seek STI testing for personal reasons generally did not experience self-consciousness during the testing process); the age of their partners (there was evidence that respondents felt more embarrassed and ashamed about informing older partners than they did about informing partners of their own ages); the settings in which respondents accessed for STI testing (those who sought STI testing from specialist settings experiencing more self-consciousness than those who sought testing from GP settings); the testing method that was used on them (women who had to take cervical swabs feeling more embarrassed and ashamed than women who only had to take urine tests); whether or not respondents tested positive for STIs (with those who had feeling more ashamed than those who had not); whether or not respondents tested positive for STIs that impacted upon their appearances (with those who had experiencing greater self-consciousness); partner notification (one area where male and female respondents differed was in relation to how they felt about the thought of not informing their partners, with female respondents indicating that they would experience more guilt than males if they did not do so); the length of treatment for their STIs (with respondents whose treatment went on for a significant period of time experiencing more embarrassment and shame than respondents whose STI could be treated with a significant doss). As noted earlier, the overall theme of this article 'self-conscious emotions act as significant barriers to testing' emerged during the period in which the study was being conducted; and as such we did not originally set out to relate self-conscious emotions to specific demographic variables. It may well be that future studies, building on the work presented here, will be able to do this and explore whether or not self-consciousness can be related to specific demographic variables for young adults seeking STI testing in Ireland.

The findings of this study suggest that there are multiple triggers of self-conscious emotions in the STI testing process, ranging from the initial decision to seek testing, right through to the experience of accessing treatment. These emotions can have negative impacts on individuals' willingness to seek treatment, to inform their partners about positive diagnoses of STIs, and on young adults' interpretations of the STI testing process. The role of self-conscious emotions therefore needs to be given consideration in policy development and service provision [8], as outlined above and summarized here. The findings of this study suggest several areas for public health and health service interventions to reduce young adults' feelings of self-consciousness in the STI testing process. Where implemented, they should then be promoted in ways that will reach young people.

Firstly, the health services should ensure that STI testing is anonymous. It might also be useful for efforts to be made to encourage young people to attend for testing with their peers. A variety of settings, generalist and specialist, should be offered and easily accessible. Secondly, healthcare professionals should be trained and audited for the appropriateness of their interactions with young adults attending their clinics. Strategies to reduce distress should be considered, such as allowing young adults complete answers on their sexual history in their own time on a questionnaire sheet.

Thirdly, non-invasive detection methods such as urine testing for STIs such as Chlamydia should be offered where this is appropriate, for example in initial screening. This would facilitate screening in a wider range of non-clinical as well as clinical settings. Fourthly, seeing the same healthcare professional from initial meeting through to treatment, where possible, would help build trust and help to reduce the shame and embarrassment that young adults often feel during the STI testing process. Such measures could help make the STI testing experience a more positive one for young adults and increase their willingness to become ambassadors for STI testing and sexual health services in the future.