Reason for seeking STI testing as a trigger for self-conscious emotion
Respondents sought STI testing for one of four reasons: 1). They had unusual symptoms near their genital regions; 2). They were required to by an employer; 3). They were in a sexual relationship and being about to stop using condoms; and 4). They had had unprotected sex with a stranger. Respondents who sought STI testing for the first, third and fourth of these reasons experienced anxieties about their risk status (i.e. about whether or not they had an STI), which prompted them to seek testing. These respondents did not, however, associate significant shame or embarrassment with their decision to seek testing.
I was up the walls. Completely up the walls. Just because I' m a worrier by nature. I'd just sit there and be like, 'oh God, the organisms are multiplying, it's getting worse'. (F/late 20s/urban GP/-).
Chlamydia is such a scary, scary thing now, because it's, you know, asymptomatic (F/late 20s/urban GP/-).
I have always been scared shitless of getting something like HIV or even syphilis or genital warts and I remember in school they'd show us pictures of black rot and stuff like that and that would just scare the shit out of you. So I had to go. (M/early 20s/student health GP/-).
Respondents who sought STI testing because they had had unprotected sex also felt anxious about their risk status.
That time because I knew I'd had unprotected sex I was quite unnerved by the fact that I could have something. (F/early 20s/urban GP/-).
However they also felt ashamed and embarrassed at the behaviors that had led them to seek STI testing, principally because they felt that these behaviors violated salient social norms governing how sexual risk was supposed to be managed (i.e. responsibly and carefully).
It's the whole embarrassment, the shame because you made a mistake you know. (F/late 20s/urban GP/-).
I felt ashamed first because you know you should be taking protection. You know it's [unprotected sex] something you' re not supposed to do you know. (F/early 20s/urban GP/-).
Embarrassment associated with talking to peers and partners about STI testing
Once they had decided to seek STI testing, respondents (whatever their initial reason for deciding to seek STI testing) were faced with another decision: whether or not to inform their partners and peers about their intention to go for testing. Many respondents felt embarrassed about the thought of doing so, concerned that their social identities would become discredited and their partners or peers would view them negatively.
Interviewer: Do you think you would have ever been the one to bring testing up with your partner first?
Respondent: No. I'd have felt shy and a bit embarrassed (M/early 20s/student health GP/-).
I suppose it's embarrassing to bring it up. You feel kind of dirty or something. (F/mid 20s/rural GP/-).
Respondents found it easier to talk to partners and friends whom they trusted and were close to. They felt that these people would not negatively evaluate them, and so respondents' concerns about embarrassment or identity threat did not become significant barriers to communication. Respondents were most likely to keep information from friends whom they knew but did not know well, and whom they could not be sure would not judge them.
It is notable, however, that even respondents who talked to their friends about their decision to seek STI testing could find it embarrassing to do so, particularly at first. Some respondents employed distancing strategies when talking to their friends about STI testing. One such strategy was to describe STI testing as an action that respondents had engaged in in the past. Consequently, testing was less likely to be seen by respondents as something on which their current social identities could be negatively assessed.
You'd think that girls would talk a lot about things like that [STIs]. But as a group we' re actually quite embarrassed about that kind of thing and we would mainly talk past tense about that kind of stuff. We say 'oh yeah, that happened to me too'. I'd never consider telling them it's happening right now. (F/late 20s/urban GP/-).
Keeping this information secret from partners was more difficult, though some respondents did so. Even respondents who talked to their partners about their need to go for testing, however, could feel embarrassed about having these conversations.
He [partner] just said he wanted to go [for testing]. I didn' t ask him about his experience. I was more kind of embarrassed about my own experience. (F/late 20s/Family planning/-).
Most respondents reported having sexual partners of approximately the same age as themselves. One female respondent, however, reported having a sexual partner who was significantly older than herself. She also reported that the age difference between herself and her partner inhibited her willingness, and increased her embarrassment, about talking to her partner about STI testing.
The respondent indicated that she had learned to play a role as a relatively powerless, desexualized innocent in her relationship with her partner, whom she represented as an older, judgmental, male authority figure. She felt that communicating to this partner that she was in need of STI testing would be an assault on the virtuous, feminine identity that she had previously established with him. She was reluctant to let this happen, which accounted for the feelings of discomfort that she experienced in relation to talking to her partner about testing.
The guy I' m with is older than me, he's a business man. I' m a student. I'd feel more uncomfortable talking to him about it. You'd be making suggestions about yourself too. You' re trying to come across as a good girl and then maybe all [sexual activities engaged in the past] hasn' t been so good in the past. (F/late 20s/family planning/+).
Shame and embarrassment associated with accessing STI testing facilities
Accessing healthcare settings for testing was considered to be an embarrassing event by many repondents. Walking into a setting and making an appointment with reception staff was an instance where respondents might have to reveal discrediting information about themselves to strangers such as reception staff and passers-by. Respondents often felt self-conscious about revealing this information to these people.
Respondents who were required to state the reason for their appointment to reception staff, and respondents who went for testing in healthcare settings whose sole purpose was to offer STI testing, reported experiencing greater embarrassment than respondents who did not have to reveal the reason for their appointment to staff receptionists. Settings that offered multiple health services apart from STI testing (such as GO practices) afforded respondents more anonymity. Respondents could be attending these settings for any reason, and so these settings were less likely to trigger self-conscious emotions in respondents.
I just went away and made the appointment in the clinic and I kind of felt a bit awkward because I was slightly embarrassed. You kind of felt a bit like you shouldn' t be sitting here in the first place. (F/late teens/student health/-).
There's just such a stigma attached to it that you know, I can' t go in case somebody sees me. There's an awful fear of 'what will people think'. (F/mid 20s/STI/+).
Several respondents reported that anticipated embarrassment influenced their decision about where to seek STI testing. These respondents thought (prior to seeking testing) that certain settings would be more likely to embarrass them than others (because these settings lacked identity-protecting orientations); these 'embarrassment-prone' settings were subsequently avoided in favor of settings where respondents thought that they would feel more comfortable and less self-conscious.
Well I did consider going to the specialist clinic but I never wanted to go. I'd put it off. Because of the fear of how you'd feel being over there. (M/late 20s/urban GP/-).
Interviewer: So if you had gone to the specialist clinic would you have felt self- conscious?
Respondent: Definitely, yes. Which like I was saying is one of the reasons why I didn' t go (F/mid 20s/urban GP/-).
Sitting in clinic waiting rooms was considered to be an unpleasant activity by many respondents, particularly those attending specialist STI settings. Respondents felt that merely being in these rooms undermined their identities, transmitted discrediting information about them to other people in the waiting areas, for example other individuals waiting for testing, receptionists, porters and even individuals walking by the clinic. This realization could trigger strong feelings of discomfort and self-consciousness in respondents.
The waiting room seemed really seemed dark and foreboding, I suppose, and you feel like shameful as well. (F/late 20s/STI/-).
It kind of feels, I don' t know, it feels dirty a little bit. They' re all looking at you as if to say well 'I know what he's here for' (M/late 20s/urban GP/-).
The social characteristics of who were waiting in the clinic reception areas played a role in determining the degree of self-consciousness that respondents experienced while they waited to be called for testing. Self-consciousness tended to increase if respondents felt that clinic audiences were people 'unlike themselves' (opposite age/gender/sexuality), and were consequently more likely to judge or assess them.
I had to sit in the waiting room, everyone knows I was there for an STI. It was just a bit embarrassing. There was a lot of men there, a lot of older men and that was embarrassing. (F/early 20s/STI/+).
There was four young fellas sitting there. I felt a bit embarrassed cos I was the only girl there. (F/early 20s/Ballymun/+).
Conversely, respondents' feelings of embarrassment were likely to attenuate if they felt that people in the waiting room were 'people like themselves' (same gender/age/sexual orientation), and likely to have supportive orientations towards respondents.
Like everyone's the same there. It's a gay man's project. You' re all there for the same reason. You' re only going up there to get tested. There's nothing embarrassing about it (M/late 20s/MSM/-).
You just feel more comfortable waiting when it's only women. You' re not going to run into somebody you know, especially a male. (F/late 20s/STI/+).
There was evidence that clinic staff who made efforts to make respondents feel comfortable, and indicate to respondents that they would not be negatively evaluated, could reduce respondents' feelings of embarrassment and shame.
I guess there's a certain openness in that clinic, there's nothing cloak and dagger about it. The guy who seems to run the operation down there seems to be on the ball and makes people feel comfortable. And also, on a personal note, I don' t feel embarrassed being somewhere like that. The staff are incredibly friendly. (M/late 20s/MSM/+).
Respondents who attended multi-purpose settings such as general practices generally felt less self-conscious while waiting to be called for their tests than did their counterparts who attended specialist clinics. In the former, 'audience members', i.e. other patients and receptionists, did not know the reasons why respondents were attending these settings. Respondents' identities were therefore not under threat to the same degree as they would have been in more openly 'discredited'  settings and self-conscious emotions were less likely to emerge.
On occasions, however, respondents attending these settings could be forced to account for their presence within them, for example because they encountered someone whom they knew in the waiting room. Such forced accountings were often described as embarrassing incidents, because they threatened to undermine respondents' identities in front of other people in the waiting areas.
I was collecting my results. And I saw this guy who I knew. I was like 'oh God, of all things, this is just great'. And he just kind of roared it out. A room full of people. 'What are you doing here? You should be at the doctor on the other campus'. I felt like dying (F/late teens/student health/-).
To help manage feelings of embarrassment and shame, many respondents (particularly female respondents) brought close friends or partners with them when they went for testing. Peers and partners helped respondents to define their STI testing activities as normal, healthy (and even fun) activities to engage in, rather than as deviant practices. Partners and peers could provide identity support to respondents, highlighting that others thought positively about them and that respondents were as 'normal' as everyone else.
I kind of went [for testing] for a giggle with some of the girls. Because it's free and it's so anonymous it's something that you can just do. (F/early 20s/urban GP/-).
I think because I' ve gone with a couple of friends, that feeling of shame isn' t there. (F/early 20s/student health GP/-).
Shame and embarrassment experienced by respondents during interactions with healthcare professionals
Interactions with healthcare professionals had the potential to induce feelings of shame and embarrassment in respondents. They were often worried that healthcare professionals would negatively evaluate them (for being promiscuous, for being careless and for needing to engage in a stigmatized activity such as STI testing), and thereby shame or embarrass them.
The worst thing about going for testing is facing your fears. Facing a fear of having to first of all, be judged. You have this feeling it's going to be cringy [embarrassing/shameful] and this person might pass a comment on you. (F/late 20s/family planning/+).
Nevertheless, about two thirds of respondents reported having positive interactions with healthcare professionals (particularly with professionals who were of the same age/gender as themselves), which served to reduce these respondents' feelings of self-consciousness. Positive interactions were characterized by non-judgmental and accepting stances on the part of treating healthcare professionals.
About one third of respondents, however, reported having negative interactions with healthcare professionals (irrespective of whether these professionals were of the same gender or age as respondents) that served to heighten their feelings of self-consciousness. The reasons for negative interactions were similar in each case: the healthcare professional was perceived to have judged respondents.
As soon as I mentioned I was single her attitude changed and she was completely horrible and basically gave out to me despite the fact I was always [sexually] careful [used condoms]. Basically treated me like a complete idiot. I was treated like dirt. Horrible, horrible experience. (F/mid 20s/FP/+).
Every question she asked me she kind of looked at me like, like 'don' t lie to me'. Someone is knit picking at your personal life. It's a bit daunting. You kind of feel guilty that you were even having sex in the first place, never mind sitting there for an STI test. (F/late teens/DIT/-).
Respondents used a variety of impression management activities to protect their identities and manage their feelings of self-consciousness during negative interactions with jusdgemental healthcare professionals,, such as downplaying the number of sexual partners that they had had (so as to present themselves as individuals who were not careless, promiscuous 'sluts' ).
If the person whose asking you 'how many partners do you have?' seem a bit serious and looking down on you, that puts you off answering properly. You' ll kind of reduce the number by half or a third, whatever. Just to make yourself look better (F/late 20s/family planning/-).
The methods that healthcare professionals used to test for STIs also determined the intensity of the feelings of shame and embarrassment that respondents' experienced. Urine tests and blood tests were considered to be the least embarrassing tests to take; respondents could take these tests in private, or only have to expose 'public' parts of their bodies such as their arms to the treating healthcare professional.
A urine test is not that bad cos you just go to the toilet and do it yourself (F/early 20s/urban GP/-).
Female respondents who took a cervical swab test, however, usually found the experience to be embarrassing; cervical swab tests violated norms of cleanliness, modesty and privacy that recommend that women do not reveal their 'dirty private parts'  to strangers.
She [doctor] kind of just says 'ok, go in there, take off your clothes and lie up on the bed'. It's embarrassing having somebody you don' t know do that. (F/early 20s/fp/-).
A minority of respondents who took a cervical swab test reported feeling shamed (rather than embarrassed) by the experience. Shame was triggered in these respondents not only by the tests' violation of modesty norms, but also by these respondents' beliefs that they had violated norms of sexual morality and responsibility. Interestingly, some of these respondents appeared to welcome their shame, and wanted to use this shame to hurt or damage the immoral and irresponsible sides of themselves that led them to take a cervical swab exam in the first place.
I had to go in there, take off my knickers and get up on the table. I kind of felt disgusted like I shouldn' t be having sex in the first place. I shouldn' t be getting into those situations. I shouldn' t be sexually active. Basically I just felt a no sex before marriage kind of policy coming off my head. I kind of felt disgusted that way. (F/late teens/SH/-).
Respondent: The experience was very uncomfortable, up on the table and that. It was very humiliating and embarrassing. But like, my thoughts on it would I was stupid enough to have unprotected sex, 'good enough to you, like'. So therefore I had to go through the shame of admitting to it and how silly I'd been and the lying up on the table getting swabbed and that.
Interviewer: So almost like it was kind of punishment in some way.
R: Yeah, exactly. (F/mid 20s/rural GP/-).
Test positive or negative? How results affect identity
Respondents who tested negative for an STI, or who tested positive for an STI that they felt had no particular stigmatizing connotations, usually felt proud that they had sought STI testing.
It was NSU. Not too serious. So I felt good that I'd gotten the test and found out about it. (M/early 20s/SH/+).
Respondents who tested positive for an STI that had stigmatizing connotations, however, usually felt ashamed (though for some this feeling lasted for only a brief period of time).
I felt so ashamed of myself. I was like 'God, how could I get an STI?' I never would have thought a year ago, two years ago, that I would get an STI. How could this happen to me, how could I be so careless. (F/early 20s/STI/+).
I was mortified. I sat and I think I cried for about two hours when I got home. I felt disgusted and embarrassed and very foolish. (F/late 20s/GP/+).
There was evidence that shame and self-disgust was stronger in respondents who had been diagnosed with STIs that affected their appearance.
It's the fact that warts changes what you look like. You' ve a constant reminder of 'that's disgusting'. You feel a bit like...it's just the stigma. Something like Chlamydia is a clean disease. You don' t see anything. It's just there. Like herpes, genital lice, genital warts, it's unsightly. (F/early 20s/STI/+).
Being diagnosed with an STI could have negative impacts on respondents' sexual practices. This tended to happen when respondents' internalized negative ideas of what a person with an STI 'was', which led them to experience an 'altered shame-based self-definition'  and lose their previously held 'respectable' self-concept.
Respondent: After I was diagnosed I basically didn' t care any more and started having one night stands for about a year after. I went off the rails and became really slutty. It did make me think I must be one of 'those' girls if I got Chlamydia. It made me think I was a slut even though I wasn' t and I ended up acting that out because I thought, it must be true if I have an STI. I wouldn' t have put myself in that category and I was like 'I must be in that category, or I wouldn' t have got this'. (F/mid 20s/GUM/+).
Notifying partners and others as an emotional trigger
Notifying sexual partners (past and present) about a positive STI diagnosis was considered to be an embarrassing activity by most respondents.
I'd just be absolutely mortified. It would really depend on the person. If they said to me go and tell those two people you had a one night stand with, then I'd be like absolutely no way. (F/early 20s/STI/+).
And then having to sit down and make the call to them, that's where the embarrassment came in. (F/late 20s/rural GP/+).
A minority of respondents indicated that they would not inform their partners about positive STI diagnoses so as to avoid having embarrassing confrontations with them. The majority of respondents, however, indicated that they would inform their partners about their diagnoses. These respondents described partner notification as a correct, responsible practice to engage in, and indicated that they would feel guilty if they did not engage in it.
Female respondents experienced feelings of guilt particularly strongly; these respondents' feelings were triggered by thoughts of how STIs could affect their partners' future girlfriends (i.e. guilt was directed towards individuals these respondents could easily empathize with).
I had to pick up the phone and speak to him [ex-partner] about it. I don' t think I could ever forgive myself if in five or ten years time an ex-partner's partner couldn' t have children because she'd had Chlamydia for so many years and never knew. As a woman I could never forgive myself. (F/late 20s/GP/+).
I would feel enormous guilt if I gave somebody else an STI and I didn' t tell them about it, I really would. I would feel I had put a huge burden on them that they had to deal with (F/early 20s/STI clinic/+).
Respondents also described feeling ashamed at the thought of informing their parents and friends that they had been diagnosed with an STI.
I was afraid my parents would be ashamed of me. I was already not feeling too brilliant about myself, so I was worried that my parents would be disappointed in me and ashamed of me. (F/early 20s/GP/-).
Some respondents avoided informing other individuals about their diagnosis because they felt that these individuals would attempt to take ownership of their experiences, and prevent respondents from processing their feelings of shame and embarrassment.
I didn' t want to tell my mother. I just knew the way she'd react. Whenever anything bad happens she's too pragmatic about it. Just get up and brush it off. Sometimes you can' t deal with that. You' re like, no, 'let me be upset. I am ashamed'. (F/early 20s/STI/+).
Respondents who tested positive for an STI, and whose treatment regimen consisted of taking a single dose of medication (for example, for Chlamydia) from the treating healthcare professional reported less treatment-orientated shame and embarrassment than respondents who had to return multiple times to their healthcare clinic for treatment (for example, because they had a viral STI such as Herpes), or who had to access treatment from public pharmacies.
I had to go in [to the hospital every month [for treatment for Herpes] and it was painful and embarrassing. (F/late 20s/STI/+).
Respondents who obtained treatment from pharmacies experienced embarrassment for much the same reasons that respondents accessing healthcare settings for testing did: they might have had to reveal discrediting information about themselves to people whom they did not know or trust. These respondents therefore engaged in a variety of impression management activities in order to minimize the risks of other people finding out about their diagnoses, such as seeking treatment from pharmacies that they would not usually attend.
My friend works in a chemist in town and I didn' t go to that one. I did go to another one in town. I didn' t want to go into her chemist cos I know the people there. I wasn' t comfortable there. (M/late 20s/MSM/+).
Respondents whose treatment lasted over an extended period of time, for example because they had been diagnosed with viral STIs, needed to manage ongoing feelings of shame and self-consciousness. In order to emotionally cope with their experiences, these respondents described needing to distance and dissociate themselves from their treatment activities.
It was very clinical going for the medication. I'd go to the hospital at this time every whatever. Get the bus, go in, make sure it doesn' t clash with any lectures. Get there early, be one of the first people there all that kind of thing. Then forget about it for another month. Just make sure I used the cream they gave me. If I was thinking about it a lot I would have gone mad. I just had to become automatic. I knew I had to get rid of it but again it was a bit like no one else is going to do it for you. I don' t know (starts crying). I don' t know why I' m getting upset, it was a year ago. But it's never just a normal trip to the clinic for anyone. There's always going to be deep emotions involved for people. (F/early 20s/STI/+).