ORIGINAL STUDY
Determinants of Chlamydia, Gonorrhea,
and Coinfection in Heterosexual Adolescents Attending
the National Public Sexually Transmitted Infection
Clinic in Singapore
Raymond Boon Tar Lim, MBBS, MPH,* Mee Lian Wong, MD, MPH,* Alex Richard Cook, PhD,*
Cyrille Brun, MSc,* Roy K.W. Chan, MBBS, MRCP,* Priya Sen, MBBS, MRCP,
and Martin Chio, MBBS, MRCP
Background: Amidst recent trends in rising rates of chlamydia and gon-
orrhea among Singaporean adolescents, there are limited data on risk fac-
tors associated with these infections that may inform prevention strategies
in this population.
Methods: A cross-sectional study of chlamydia and gonorrhea positivity
was conducted among 1458 sexually active heterosexual adolescents be-
tween 14 and 19 years old attending the national public sexually transmitted
infection clinic from 2006 to 2013. The association with demographic and
behavioral characteristics was assessed by crude prevalence ratio, and neg-
ative binomial regression modeling was used to obtain adjusted prevalence
ratios (aPRs).
Results: Chlamydia positivity was found in 23.6% of males and 36.6% of
females, gonorrhea positivity in 33.1% of males and 15.9% of adolescent
girl, and coinfection positivity in 10.2% of males and 10.1% of females.
In multivariable analysis, chlamydia was positively associated with being
Malay (aPR, 1.6; 95% confidence interval [CI], 1.12.1) and inconsistent
condom use for vaginal sex (aPR, 6.5; 95% CI = 2.417.4) in males and
with being Malay (aPR, 1.9; 95% CI = 1.52.4), inconsistent condom use
for vaginal sex (aPR, 2.0; 95% CI = 1.13.9), and number of lifetime partners
in females (aPR, 1.1; 95% CI = 1.01.1). Gonorrhea was positively associ-
ated with being Malay (aPR, 3.2; 95% CI = 2.44.4), inconsistent condom
use for vaginal sex (aPR, 5.4; 95% CI = 2.114.4), and number of lifetime
partners (aPR, 1.1; 95% CI = 1.01.1) in males and with being Malay (aPR,
3.7; 95% CI = 2.45.7) in females. Malays had a higher proportion of
sexual risk behaviors compared with the non-Malays.
Conclusions: Ethnicity and high-risk sexual behaviors are important de-
terminants of chlamydia, gonorrhea, and coinfection for adolescents attend-
ing this clinic. Targeted interventions are needed to lower the prevalence
of high-risk sexual behaviors for the Malay adolescents in this clinic.
E ach year an estimated 333 million new cases of curable sexu-
ally transmitted infections (STIs) occur worldwide, with the
second highest rate in the 15- to 19-year age group, meaning that
From the *Saw Swee Hock School of Public Health, National University of
Singapore, Singapore; and Department of Sexually Transmitted Infec-
tions Control, National Skin Centre, Singapore
Conflict of interest: The authors declared no conflict of interests.
Funding sources: The study is funded by the National Medical Research
Council, Singapore, which was not involved in (1) study design; (2) the
collection, analysis, and interpretation of data; (3) the writing of the
manuscript; and (4) the decision to submit the manuscript for publication.
Correspondence: Mee Lian Wong, MD, MPH, Saw Swee Hock School of
Public Health, National University of Singapore, Tahir Foundation
Building, 12 Science Drive 2, #10-01, Singapore 117549, Singapore.
E-mail: ephwml@nus.edu.sg.
Received for publication June 28, 2014, and accepted May 28, 2015.
DOI: 10.1097/OLQ.0000000000000316
Copyright 2015 American Sexually Transmitted Diseases Association
All rights reserved.
450 Sexually Transmitted Diseases
Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
1 in 20 adolescents will contract an STI annually.1 The incidence
of the top 2 bacterial STIs worldwide, chlamydia and gonorrhea,
also applied to Asia, with 47.2 and 67.4 million cases, respectively,
in 2008.2 The incidence of STIs in the 10- to 19-year age group
has increased from approximately 50 cases per 100,000 population
in 2002 to approximately 150 cases per 100,000 population in 2008
in Singapore, with chlamydia and gonorrhea being the top 2 STIs.3
This has occurred concurrently with an increase in reported teenage
abortion from 2600 in 1998/1999 to 2800 in 2007/2008.4
Given that adolescents made up 18% of the world's current
population and more than half of them live in Asia,5 policymakers
and public health professionals need to identify the determinants
of STIs in the Asian adolescent community to better design educa-
tion and prevention programs. Research has shown several risk
factors to be associated with the acquisition of chlamydia or gonor-
rhea. These include sociodemographic/economic factors, lifestyle
habits, and risky sexual behaviors. Sociodemographic/economic
determinants include young women,68 particularly female adoles-
cents6,8 who are at higher risk for chlamydia, whereas lower socio-
economic status is associated with gonorrhea.9,10 Lifestyle habits
such as smoking811 and alcohol use1114 have also been reported
to be associated with chlamydia. Sexual behavior determinants
such as multiple sexual partners11,15 and inconsistent condom
use6,7,15,16 have been reported to be risk factors for chlamydia
and gonorrhea.
To our knowledge, STI prevalence studies on adolescents
were mostly in Western populations13,17 and examined either chla-
mydia or gonorrhea, but not both.12,13,17 Although reported pre-
marital sex is less common in Asia compared with the West among
the adolescents,18 it is on the rise and this continuing increase in
adolescent premarital sexual activity in the presence of generally
low contraceptive usage among this group18 has significant effects
on adolescent health, potentially increasing their risk of contracting
STIs such as chlamydia and gonorrhea. This poses significant risk
for long-term reproductive health sequel in adolescents, affecting
their fertility in the future.19 The aim of this study is to evaluate
the positivity of chlamydia, gonorrhea, and coinfection and their
associations with sociodemographic/economic factors, lifestyle
habits, and sexual behaviors in the adolescent population in
Singapore, made up of Chinese, Malay and Indian ethnicities.
MATERIALS AND METHODS
Study Design
This was a cross-sectional study on sexually active hetero-
sexual adolescents attending the Department of Sexually Transmit-
ted Infections Control (DSC) Clinic from July 2006 to September
2013. The DSC Clinic is the only national public specialist clinic
for the diagnosis and treatment of STIs in Singapore. The inclusion
Volume 42, Number 8, August 2015

criteria for the study were new clinic adolescent patients between
the ages of 14 and 19 years whose most recent sexual encounter
was heterosexual intercourse, defined as having intercourse with
a partner of the opposite sex; intercourse was defined as any one
of the following acts: the penis entering the vagina, an adolescent's
mouth touching another person's genitals, or the penis entering a
female's anus. The exclusion criteria were adolescents returning
for follow-up visits and rape cases. Each adolescent who presents
to the clinic for the first time has to consult a doctor who will then
take a history and conduct a physical examination before the ado-
lescent takes the STI tests. Information on symptoms of genital
discharge or pain on urination and signs on genital ulcer or growth
was available for this study. Although all sexually active adoles-
cents have to undergo testing for both chlamydia and gonorrhea
in the clinic regardless of whether there is any symptom or sign,
they can refuse. The diagnosis of chlamydia and gonorrhea infec-
tion was made based on positive urine specimen using the Cobas
Amplicor polymerase chain reaction (PCR) assay.20
Behavioral Data Collection
We administered a questionnaire to all adolescents after
they have signed the consent form (16 years or older) after receiv-
ing explanation and before they received their STI test results. For
those younger than 16 years, accompanying parents, guardians, or
juvenile home officers signed the consent form, and the adolescent
signed the assent form. These people accompanying the younger
adolescents had to leave the room during the administration of
the questionnaire. The first part of the questionnaire was interviewer
administered and consisted of questions on sociodemographic/
economic status. These included sex (male or female), age (years),
ethnic group (Chinese, Malay, Indian, or others), housing (public or
private housing), living arrangements (lives with parents or not),
and schooling status (enrolled in school or not). Ethnic group
was dichotomized into 2 groups, non-Malay or Malay. The Chinese
and Indians were combined into 1 group, the non-Malays, on the
basis that the proportion of Indians in the study was small and their
rates of STIs were similar to the Chinese. The second part of the
questionnaire was self-administered and consisted of questions on
their lifestyle habits and sexual behavior, with the most sensitive
questions placed at the end. These included smoking status (never
smoker, which meant never smoked before; past smoker only,
which meant was a smoker previously but had quit smoking at
the time of the study; and current smoker, which meant currently
smoking at the time of the study), alcohol status (nondrinker or
drinker), ever use of recreational drug (no or yes), and ever in-
volvement in gang fight (no or yes). Sexual behavior assessed in-
cluded age at first sex, number of lifetime sexual partners, and
consistent condom use for vaginal sex (never, occasional, and
always). Consistent condom use for vaginal sex was dichotomized
into 2 groups: no (never and occasional) and yes (always). Ano-
nymity and confidentiality were maintained by not asking any per-
sonal identifiers in the questionnaire.
Statistical Analyses
Only participants with complete interview and STI results
were included in the analysis. For each sex, we calculated the pro-
portion tested positive for chlamydia, gonorrhea, and coinfection
respectively. Next, we stratified by sex and computed the propor-
tions tested positive according to demographic and behavioral
characteristics. Positivity of infection was taken to be a proxy for
prevalence in this cross-sectional analysis. Next, we evaluated
the association between positivity of each infection with demo-
graphic and behavioral characteristics. As the outcomes were com-
mon, we used negative binomial regression to obtain the crude
prevalence ratio (PR) and 95% confidence interval (CI) of each
Sexually Transmitted Diseases Volume 42, Number 8, August 2015
Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Chlamydia/Gonorrhea Among Singaporean Adolescents
characteristic with chlamydia, gonorrhea, and coinfection, respec-
tively. A P value of 0.05 or less was considered statistically signif-
icant. Next, we conducted negative binomial regression using
backward stepwise elimination procedure to obtain the adjusted
PR (aPR) and 95% CI in the multivariable analysis. All character-
istics with P < 0.1 in the bivariate analyses were entered into each
of the respective multivariable models to avoid the exclusion of
any variable that may be marginally significant at selection but be-
comes statistically significant in the final model. Because Malay
ethnicity was found to be a consistent determinant for chlamydia,
gonorrhea, and coinfection in multivariable analysis, we performed
subanalysis of the differences in distribution of sociodemographic/
economic, lifestyle habit, and sexual behavioral characteristics
between the Malays and non-Malays by sex. Categorical variables
were compared with the use of the 2 test and continuous variables
with the independent-sample t test. The study was approved by the
National Healthcare Group Institutional Review Board. Data analy-
sis was performed using Stata (version 11.2; StataCorp LP, College
Station, TX).
RESULTS
Within the study period, 1893 adolescents visited the DSC,
of whom 1458 (77%) of them agreed to participate in the study.
The top 2 reasons for nonparticipation were time constraints
(32.0%) and lack of interest (28.0%). Urine PCR test for chla-
mydia was conducted on 1265 of the 1458 adolescents. For the
evaluation of the determinants of chlamydia, we analyzed 1098
of the 1265 adolescents (86.8%) after excluding 167 (93 homosex-
uals and 74 had missing data due to incomplete questionnaire).
Urine PCR test for gonorrhea was conducted on 1272 of the
1458 adolescents. For the evaluation of the determinants of gonor-
rhea, we analyzed 1100 (86.5%) of the 1272 adolescents after ex-
cluding 172 (97 homosexuals and 75 had missing data due to
incomplete questionnaire). Urine PCR test for coinfection was per-
formed on 1226 of the 1458 adolescents. For the evaluation of the
determinants of coinfection, we analyzed 1065 of the 1226 adoles-
cents (86.9%) after excluding 161 (88 homosexuals and 73 had
missing data due to incomplete questionnaire).
Table 1 shows the distribution of the various characteristics
for those with chlamydia, gonorrhea, and coinfection positivity, re-
spectively. For chlamydia, 30.4% were found to be positive, where
females (36.6%) had higher positivity compared with the males
(23.6%). Among those with chlamydia positivity, 46.3% of males
and 57.4% of females reported at least 1 symptom or sign. For
gonorrhea, 24.1% were found to be positive, where males (33.1%)
had higher positivity compared with the females (15.9%). Among
those with gonorrhea positivity, 46.0% of males and 52.8% of fe-
males reported at least 1 symptom or sign. For coinfection, 10.1%
were found to be positive, where males (10.2%) and females
(10.1%) had similar positivity. Among those with coinfection posi-
tivity, 43.1% of males and 57.9% of females reported at least 1
symptom or sign. Among those who were asymptomatic, 28.3%,
25.1%, and 9.9% were tested positive for chlamydia, gonorrhea,
and coinfection, respectively.
Table 2 shows the crude analyses between the various char-
acteristics with chlamydia, gonorrhea, and coinfection, respectively.
Compared with non-Malays, Malays had a higher positivity in chla-
mydia (PRs, 2.1 [95% CI = 1.52.9] for males and 2.0 [95% CI =
1.62.5] for females), gonorrhea (PRs, 4.6 [95% CI = 3.36.3] for
males and 3.7 [95% CI = 2.45.7] for females), and coinfection
(PRs, 6.1 [95% CI = 3.012.2] for males and 4.7 [95% CI =
2.58.6] for females) for both sexes. Compared with nonsmokers,
current smokers had the highest positivity in chlamydia (PRs, 2.4
[95% CI = 1.44.1] for males and 1.5 [95% CI = 1.11.9] for
451
Lim et al.

TABLE 1. Positivity of Chlamydia, Gonorrhea, and Coinfection Among Singaporean Adolescent STI Clinic Attendees by Sociodemographic
Characteristics and Risk Behaviors
Chlamydia (n = 1098) Gonorrhea (n = 1100) Coinfection (n = 1065)
Male (n = 521) Female (n = 577) Male (n = 526) Female (n = 574) Male (n = 502) Female (n = 563)
Positive Positive Positive Positive Positive Positive
Characteristic (n = 123; 23.6%)* (n = 211; 36.6%)* (n = 174; 33.1%)* (n = 91; 15.9%)* (n = 51; 10.2%)* (n = 57; 10.1%)*
Ethnic group, n (%)
Non-Malay 47 (15.9) 80 (25.1) 38 (12.9) 23 (7.2) 9 (3.2) 12 (3.9)
Malay 76 (33.6) 131 (50.8) 136 (58.9) 68 (26.6) 42 (19.3) 45 (17.9)
Housing, n (%)
Private housing 6 (12.0) 11 (21.2) 5 (9.8) 3 (5.6) 1 (2.1) 2 (3.9)
Public housing 117 (24.8) 200 (38.1) 169 (35.6) 88 (16.9) 50 (11.0) 55 (10.8)
Living arrangement, n (%)
Lives with parents 81 (21.4) 143 (35.2) 113 (29.8) 60 (14.8) 34 (9.3) 38 (9.5)
Does not live with parents 42 (29.6) 68 (39.8) 61 (41.5) 31 (18.3) 17 (12.3) 19 (11.7)
Schooling status, n (%)
Enrolled in school 56 (21.7) 107 (29.1) 113 (29.8) 60 (14.8) 34 (9.3) 38 (9.5)
Not enrolled in school 67 (25.5) 104 (49.8) 61 (41.5) 31 (18.3) 17 (12.3) 19 (11.7)
Age, mean (SD), y 18.2 (1.1) 17.8 (1.1) 18.0 (1.1) 17.6 (1.2) 18.0 (1.2) 17.6 (1.3)
Smoking status, n (%)
Never smoker 13 (11.4) 58 (28.6) 14 (12.5) 23 (11.5) 4 (3.6) 13 (6.5)
Past smoker only 4 (17.4) 18 (35.3) 6 (25.0) 14 (25.9) 1 (4.6) 8 (16.3)
Current smoker 106 (27.6) 135 (41.8) 154 (39.5) 54 (16.9) 46 (12.4) 36 (11.4)
Alcohol status, n (%)
Nondrinker 33 (27.3) 61 (39.9) 48 (40.0) 28 (18.3) 14 (12.1) 20 (13.5)
Drinker 90 (22.5) 150 (35.4) 126 (31.0) 63 (15.0) 37 (9.6) 37 (8.9)
Ever use of recreational drug, n (%)
No 98 (22.4) 187 (37.0) 138 (31.2) 78 (15.6) 41 (9.7) 49 (9.9)
Yes 25 (30.1) 24 (33.8) 36 (42.9) 13 (17.8) 10 (12.5) 8 (11.6)
Ever involvement in gang fight, n (%)
No 77 (21.0) 195 (36.9) 110 (30.2) 80 (15.3) 31 (8.8) 52 (10.1)
Yes 46 (29.7) 16 (33.3) 64 (39.5) 11 (22.0) 20 (13.3) 5 (10.6)
Consistent condom use for vaginal sex, n (%)
Yes 4 (3.6) 7 (15.9) 3 (2.8) 4 (8.9) 1 (0.9) 1 (2.3)
No 119 (29.0) 204 (38.3) 171 (40.8) 87 (16.5) 50 (12.7) 56 (10.8)
Age at first sex, mean 15.8 (1.7) 15.5 (1.6) 15.6 (1.7) 15.5 (1.6) 15.5 (1.6) 15.4 (1.5)
(SD), y
No. lifetime sexual 4.9 (3.2) 4.8 (2.9) 5.4 (3.3) 4.4 (3.0) 5.4 (3.1) 4.6 (2.6)
partners, mean (SD)

*Row percentages are presented.

females) for both sexes and gonorrhea (PR, 2.3; 95% CI = 1.34.1)
and coinfection (PR, 3.4; 95% CI = 1.39.3) in only males. Com-
pared with consistent condom users, inconsistent condom users for
vaginal sex had a higher positivity in chlamydia (PRs, 8.0 [95%
CI = 3.021.1] for males and 2.4 [95% CI = 1.34.8] for females)
for both sexes and gonorrhea (PR, 14.6; 95% CI = 4.744.7) and co-
infection (PR, 13.7; 95% CI = 1.998.1) in only males.
Table 3 shows the multivariable analysis of the determi-
nants of chlamydia, gonorrhea, and coinfection, respectively. The
estimates of the determinants were adjusted for the other covari-
ates in the model (only those with P < 0.1 were incorporated as
mentioned previously in the Materials and Methods) and thus
independently associated with the infection for that determinant.
There was no multicollinearity (variance inflation factor <2.00
and tolerance >0.52) and no notable statistical interaction among
the determinants for each of the 3 final models. Chlamydia was pos-
itively associated with being Malay (aPR, 1.6; 95% CI = 1.12.1)
and inconsistent condom use for vaginal sex (aPR, 6.5; 95% CI =
2.417.4) in males and with being Malay (aPR, 1.9; 95% CI =
1.52.4), inconsistent condom use for vaginal sex (aPR, 2.0; 95%
CI = 1.13.9), and number of lifetime sexual partners (aPR, 1.1;
95% CI = 1.01.1) in females. Gonorrhea was positively associated
with being Malay (aPR, 3.2; 95% CI = 2.44.4), inconsistent con-
dom use for vaginal sex (aPR, 5.4; 95% CI = 2.114.4), and number
of lifetime sexual partners (aPR, 1.1; 95% CI = 1.01.1) in males
and with being Malay (aPR, 3.7; 95% CI = 2.45.7) in females.
Coinfection was positively associated with being Malay in males
(aPR, 6.1; 95% CI = 3.012.2) and females (aPR, 4.7; 95%
CI = 2.58.6).
Table 4 shows the distribution of the various characteristics
by sex and ethnicity. In both sexes, there were a lower proportion
of those who stayed in private housing in the Malays compared
with the non-Malays for both sexes. There were also a greater pro-
portion of females who were not enrolled in school in the Malays
(48.6%) compared with the non-Malays (25.3%). For behavioral
risk factors, there were also a greater proportion of current smokers
in the Malays than the non-Malays for both sexes. In the males,
there was a greater proportion of Malays who ever used recrea-
tional drug and ever involved in gang fights compared with the
non-Malays. Malays reported a lower proportion of consistent
condom use for vaginal sex and earlier mean age at first sex than
did the non-Malays in both sexes. In the males, the mean number
of lifetime sexual partners was higher in the Malays (5.0) than the
non-Malays (4.0). In addition, the most common reason for clinic
attendance among the Malays was referral by another doctor to the
specialist at DSC clinic (52.6%) followed by self-referral to screen
for STIs (29.2%). This was in contrast to the non-Malays, where
the most common reason was self-referral to screen for STIs

452 Sexually Transmitted Diseases Volume 42, Number 8, August 2015

Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
 Chlamydia/Gonorrhea Among Singaporean Adolescents

TABLE 2. Crude Associations Between the Various Characteristics With Chlamydia, Gonorrhea, and Coinfection, Respectively
Crude PR (95% CI)
Chlamydia (n = 1098) Gonorrhea (n = 1100) Coinfection (n = 1065)
Characteristic Male (n = 521) Female (n = 577) Male (n = 526) Female (n = 574) Male (n = 502) Female (n = 563)
Ethnic group
Non-Malay Referent
Malay 2.1 (1.52.9) 2.0 (1.62.5) 4.6 (3.36.3) 3.7 (2.45.7) 6.1 (3.012.2) 4.7 (2.58.6)
Housing
Private housing Referent
Public housing 2.1 (1.04.5) 1.8 (1.13.1) 3.6 (1.18.4) 3.1 (1.09.3) 5.3 (0.737.4) 2.8 (0.711.1)
Living arrangement
Lives with parents Referent
Does not live with parents 1.4 (1.01.9) 1.1 (0.91.4) 1.4 (1.11.8) 1.2 (0.81.8) 1.3 (0.82.3) 1.2 (0.72.1)
Schooling status
Enrolled in school Referent
Not enrolled in school 1.2 (0.91.6) 1.7 (1.42.1) 1.3 (1.01.6) 1.9 (1.32.8) 1.3 (0.82.2) 1.9 (1.13.0)
Age 1.0 (0.91.2) 1.0 (0.91.1) 0.9 (0.81.1) 0.9 (0.71.0) 0.9 (0.71.2) 0.8 (0.71.0)
Smoking status
Never smoker Referent
Past smoker only 1.5 (0.64.3) 1.2 (0.81.9) 2.0 (0.94.7) 3.2 (1.95.2) 1.3 (0.210.7) 2.5 (1.1 5.7)
Current smoker 2.4 (1.44.1) 1.5 (1.11.9) 2.3 (1.34.1) 1.5 (0.92.3) 3.4 (1.39.3) 1.8 (1.03.2)
Alcohol status
Nondrinker Referent
Drinker 0.8 (0.61.2) 0.9 (0.71.1) 0.8 (0.61.0) 0.8 (0.61.2) 0.8 (0.51.4) 0.7 (0.4 1.1)
Ever use of recreational drug
No Referent
Yes 1.4 (0.92.0) 0.9 (0.71.3) 1.4 (1.01.8) 1.1 (0.72.0) 1.3 (0.72.5) 1.2 (0.62.4)
Ever involvement in gang fight
No Referent
Yes 1.4 (1.01.9) 0.9 (0.61.4) 1.3 (1.01.7) 1.4 (0.82.5) 1.1 (0.42.5) 1.1 (0.42.5)
Consistent condom use for vaginal sex
Yes Referent
No 8.0 (3.021.1) 2.4 (1.34.8) 14.6 (4.744.7) 1.9 (0.74.8) 13.7 (1.998.1) 4.7 (0.733.5)
Age at first sex 0.9 (0.91.0) 0.9 (0.91.0) 0.9 (0.81.0) 0.9 (0.81.0) 0.9 (0.81.0) 0.9 (0.81.0)
No. lifetime sexual partners 1.0 (1.01.1) 1.1 (1.01.1) 1.1 (1.01.1) 1.0 (1.01.1) 1.1 (1.01.2) 1.0 (1.01.1)

(46.5%) followed by referral by another doctor to the specialist at
DSC clinic (42.4%) (results not shown in Table 4).
DISCUSSION
We found a high positivity of chlamydia, gonorrhea, and
coinfection among the adolescents attending the national public
STI clinic from 2006 to 2013 in Singapore. Approximately half
of the adolescents who were tested positive reported at least 1
symptom or sign. In addition, among those who were asymptomatic,
approximately a quarter of them were tested positive for infection.
In the multivariable analysis, the significant determinants included
being Malay, inconsistent condom use for vaginal sex, and number
of lifetime sexual partners. Of note, being Malay was a consistent
determinant for chlamydia, gonorrhea, and coinfection in both
sexes. Malays had a higher proportion of behavioral risk factors
compared with the non-Malays in both sexes.
The high positivity of STIs among adolescents screened in
our clinic was generally higher compared with other published
studies in similar clinic setting: For chlamydia, our positivity rates
were 23.6% in males and 36.6% in females compared with 23% in
males and 22% in females at 5 STI clinic sites among adolescents
and young adults in the United States from 1993 to 1995,21 as well
as compared with 15.4% in males and 5.5% in females at multiple
STI clinic sites among adolescents and young adults in Canada from
2007 to 2008.22 For gonorrhea, our positivity rates were 33.1% in

TABLE 3. Multivariable Associations Between the Various Determinants With Chlamydia, Gonorrhea, and Coinfection, Respectively
aPR (95% CI)
Chlamydia (n = 1098) Gonorrhea (n = 1100) Coinfection (n = 1065)
Characteristic Male (n = 521) Female (n = 577) Male (n = 526) Female (n = 574) Male (n = 502) Female (n = 563)
Ethnic group
Non-Malay Referent
Malay 1.6 (1.12.1) 1.9 (1.52.4) 3.2 (2.44.4) 3.7 (2.45.7) 6.1 (3.012.2) 4.7 (2.58.6)
Consistent condom use for
vaginal sex
Yes Referent
No 6.5 (2.417.4) 2.0 (1.13.9) 5.4 (2.114.4) NA NA NA
No. lifetime sexual partners NA 1.1 (1.01.1) 1.1 (1.01.1) NA NA NA

NA indicates not applicable, demonstrating that the characteristic was not significant in the final multivariable model.

Sexually Transmitted Diseases Volume 42, Number 8, August 2015 453

Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Lim et al.

TABLE 4. Prevalence of Sociodemographic Characteristics and Behavioral Risk Factors by Sex and Ethnicity
Male (n = 502) Female (n = 563)
Characteristic Non-Malay (n = 284) Malay (n = 218) P Non-Malay (n = 312) Malay (n = 251) P
Housing, n (%) <0.001 <0.001
Private housing 47 (16.6) 1 (0.5) 47 (15.1) 5 (2.0)
Public housing 237 (83.4) 217 (99.5) 265 (84.9) 246 (98.0)
Living arrangement, n (%)
Lives with parents 213 (75.0) 151 (69.3) 0.2 231 (74.0) 169 (67.3) 0.1
Does not live with parents 71 (25.0) 67 (30.7) 81 (26.0) 82 (32.7)
Schooling status, n (%)
Enrolled in school 149 (52.5) 99 (45.4) 0.1 233 (74.7) 129 (51.4) <0.001
Not enrolled in school 135 (47.5) 119 (54.6) 79 (25.3) 122 (48.6)
Age, mean (SD), y 18.1 (1.0) 18.2 (1.1) 0.9 18.0 (1.1) 17.7 (1.2) <0.001
Smoking status, n (%)
Never smoker 94 (33.1) 16 (7.3) <0.001 139 (44.6) 60 (23.9) <0.001
Past smoker only 17 (6.0) 5 (2.3) 17 (5.4) 32 (12.7)
Current smoker 173 (60.9) 197 (90.4) 156 (50.0) 159 (63.4)
Alcohol status, n (%)
Nondrinker 43 (15.1) 73 (33.5) <0.001 51 (16.4) 97 (38.6) <0.001
Drinker 241 (84.9) 145 (66.5) 261 (83.6) 154 (61.4)
Ever use of recreational drug, n (%)
No 253 (89.1) 169 (77.5) <0.001 278 (89.1) 216 (86.1) 0.3
Yes 31 (10.9) 49 (22.5) 34 (10.9) 35 (13.9)
Ever involvement in gang fight, n (%)
No 215 (75.7) 136 (62.4) 0.001 288 (92.3) 228 (90.8) 0.5
Yes 69 (24.3) 82 (37.6) 24 (7.7) 23 (9.2)
Consistent condom use for vaginal sex, n (%)
Yes 99 (34.9) 8 (3.7) <0.001 31 (9.9) 13 (5.2) 0.04
No 185 (65.1) 210 (96.3) 281 (90.1) 238 (94.8)
Age at first sex, mean (SD), y 16.2 (1.8) 15.7 (1.7) 0.002 15.9 (1.7) 15.5 (1.6) 0.01
No. lifetime sexual partners, mean (SD) 4.0 (3.2) 5.0 (3.1) <0.001 4.2 (3.0) 4.4 (2.9) 0.6

males and 15.9% in females compared with 22% in males and 11%
in females in the United States,21 as well as compared with 2.4% in
males and 0.2% in females in Canada.22 For coinfection, our posi-
tivity rates were 10.2% in males and 10.1% in females compared
with 0.9% in males and 0.1% in females in Canada.22 In general, ap-
proximately half of the adolescents who were tested positive in our
study reported at least 1 symptom or sign, and the proportion of fe-
males who were symptomatic was higher than that of the males.
Concern over symptoms or signs, constituting approximately 40%
of clinic encounters, was one major factor leading to the corre-
sponding high positivity rates. Another major reason, constituting
another 47% of clinic encounters, was referrals from the primary
care setting to the only public tertiary DSC clinic for the treatment
of STIs in Singapore. The clinic routinely screens all sexually active
adolescents for chlamydia and gonorrhea, in contrast to the US Pre-
ventive Services Task Force's recommendation to screen all sexually
active female adolescents.6 Routine screening regardless of sex has
been carried out in the clinic due to a few reasons, one of which was
the high positivity of chlamydia and gonorrhea among both male
and female adolescents at the clinic, which was present even among
those who were asymptomatic. In addition, the primary reason for
clinic attendance among the males was referral by another doctor
to the specialist at DSC clinic, the only public STI clinic in
Singapore, rather than self-referral to screen for STIs. Because
males are more likely to be asymptomatic compared with females,
the clinic has extended screening to the males in addition to the fe-
males because the males are likely to be an important reservoir for
STIs as well.1 The adoption of urine-based tests also facilitates bio-
logical specimen collection because it is deemed to be less invasive
by the adolescents.
Current smoking was associated with chlamydia, gonor-
rhea, and coinfection in univariate analysis, but not in the multivar-
iable models. The findings between smoking and STIs have been
mixed11,17,23: for chlamydia, the relative risk was 2.21 (95% CI =
1.283.81) in a prospective study among 301 teenage girls be-
tween 14 and 19 years of age during 1-year follow-up in 199117;
on the other hand, smoking was not statistically associated with
chlamydia (adjusted odds ratio, 1.10; 95% CI = 0.602.10) in an-
other prospective cohort study among 1829 females aged 18 to
44 years between 1993 and 1995.23 There are 2 possible explana-
tions for the association of smoking with STIs. First, smoking
compromises the antibacterial function of leukocytes and in-
creases susceptibility to bacterial infections such as chlamydia
and gonorrhea in smokers.24 Nicotine and its metabolite cotinine
have been detected in the cervical mucus of female smokers.25
Second, smoking constitutes a marker of behavioral risk factors
and individuals with such behavior are also more likely to under-
take sexual risks,26 potentially confounding the association that
may explain why smoking was not a significant determinant in
the multivariable models in our study.
Malays had a higher risk for chlamydia, gonorrhea, and co-
infection compared with the non-Malays in our study. In the
United States, African Americans also experienced higher rates
of STIs compared with other ethnic groups such as the whites
and the Hispanics mainly because of 2 reasons.27,28 First, part-
ner choice was more highly dissortativemeaning that African
Americans who had only 1 partner in the past year were 5 times
more likely to choose African Americans who had 4 or more part-
ners in the past year compared with the whites.27,28 Second, STIs
tend to stay within the African American population because their
partner choices were more segregated (assortative mating)27,28 and
they were more likely to have concurrent sexual partnerships from
people of their own ethnicity28 compared with other groups. The
limited sexual mixing among African Americans themselves
tends to confine STIs, especially gonorrhea, within their own eth-
nic networks.27,29 These findings from the African Americans

454 Sexually Transmitted Diseases Volume 42, Number 8, August 2015

Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.

might possibly explain the higher risk experienced by the Malays
compared with the non-Malays in our study. Studies have shown
that Malays tend to spend time with friends from the same ethnic-
ity and prefer to interact with people from the same culture compared
with Chinese and Indians.30,31 This corroborates with independent
in-depth interviews among the adolescents that the sexual partners
of Malays are more likely to be from the same ethnicity compared
with the Chinese and Indians. In addition, the strict rules forbid-
ding premarital sex in the cultural and religious context of the
Malays might potentially pose a barrier to seeking screening and
treatment services early. This was supported by our results that
the proportion of Malays (29.2%) who attended the clinic due to
self-referral for STI screening was far lower than that of the non-
Malays (46.5%). Therefore, the higher positivity observed among
Malays could possibly be because they sought treatment late, and
these infections were more likely to be prevalent. Our study has al-
ready showed that the association between STIs and Malay ethnic-
ity persisted even when controlling for housing information which
is a proxy for socioeconomic status. Further studies are hence
needed to determine the reasons for the observed high risk of
Malays for STIs, as to whether they exhibit similar sexual behav-
iors as the African Americans or whether other reasons could ex-
plain this finding.
Based on our findings, targeted interventions are needed to
reduce sexual risk behaviors among the Malay adolescents, for ex-
ample, by improving their consistent condom usage and reducing
the number of sexual partners. Such interventions will need to be
delivered through appropriate channels that are easily accessed by
and acceptable to the Malay adolescents. More importantly, it is
also crucial to address the stigma associated with STIs which is
often an important barrier to prevention, screening, and care.32
Adolescents may be particularly sensitive to social judgments
and the opinions of their peers relative to other age groups, partic-
ularly in the Asian context where parents and caregivers are gener-
ally much less comfortable and confident to talk about sexuality
issues with their children.33 Therefore, a key approach for STI pre-
vention program would be to destigmatize STI screening and sex-
ual health seeking behavior in the adolescent community, ensuring
that the program is delivered in a supportive manner that promotes
future positive sexual experiences as opposed to focusing on pre-
vious mistakes and be judgmental.32
The limitations of the study include the use of cross-
sectional data which precludes any causal interpretation regarding
the relationships between the various characteristics and chlamydia,
gonorrhea, and coinfection, respectively. We could not determine
the time course, for example, whether inconsistent condom use
for vaginal sex leads to an increase risk of chlamydia or gonorrhea,
or whether the presence of STIs leads to a change in the behavior
of condom use. The assessment of the various characteristics was
based on self-report by the adolescents leading to potential re-
porting bias. Moreover, issues that implicitly relate to social norms,
like the questions on sexual risk behavior, may not be reliably re-
ported. However, we have tried to mitigate the extent of this via
several measures, such as ensuring anonymity and confidentiality
by not asking any personal identifier in the questionnaire, self-
administration of questions on sensitive issues such as behavioral
risk factors by the adolescents in a private room, and administering
the questionnaire before the adolescents received their STI test re-
sults. This was intentionally done to prevent the adolescents from
knowing their infection status beforehand, which could potentially
affect the way in how they chose to answer the questions thereaf-
ter. In addition, not all participants were screened in this study (ap-
proximately 13% were not screened). The main reasons were
refusal by the participant or that the participant had already per-
formed the screening tests in another health care institution and
Sexually Transmitted Diseases Volume 42, Number 8, August 2015
Copyright 2015 by the American Sexually Transmitted Diseases Association. Unauthorized reproduction of this article is prohibited.
Chlamydia/Gonorrhea Among Singaporean Adolescents
the attending doctor had deemed it unnecessary for a duplicate
test. It is possible that this may have distorted positivity estimates,
and a priori, it is not possible to determine the direction in which
the bias will occur. For the purpose of this study, urine test was
used to indicate the presence of gonorrhea, meaning that rectal
and pharyngeal infections might have been missed.
Our study in an STI clinicbased setting limits the general-
izability of the findings. Although 80% of the reportable STIs in
Singapore were diagnosed in this clinic, we cannot exclude the
possibility of STIs being diagnosed in the private specialized STI
clinics where screening of asymptomatic persons may also occur.
However, we believe that the number is small as all STIs are report-
able to the DSC under the Infectious Disease Act. Although we
may not be able to extrapolate our findings to the general Asian
adolescent community, we believe that these findings can be used
to inform the design of interventions targeting sexually active het-
erosexual Asian adolescents in similar clinical settings.
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