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Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025
Date: June 24, 2025
Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus.
Case: A 24-year-old woman presents to the emergency department (ED) with a two-day history of dysuria, lower abdominal discomfort, and abnormal vaginal discharge. She is sexually active with multiple male partners and does not consistently use condoms. A urine nucleic acid amplification test (NAAT) is sent, and the patient is clinically diagnosed with a possible sexually transmitted infection (STI). She is not in acute distress, has no fever, and requests discharge after symptom control.
Background: STIs such as chlamydia and gonorrhea remain significant public health concerns in the United States (US), particularly among young adults. EDs are increasingly serving as critical access points for STI screening and treatment. However, emerging evidence suggests that treatment practices may differ by patient sex, raising concerns about potential inequities in care delivery.
Women are disproportionately affected by the long-term sequelae of untreated STIs, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Despite this, treatment disparities may exist. Men presenting with STI symptoms often receive expedited care, while women, even when symptomatic or diagnosed, may not receive timely or adequate treatment. Potential explanations include differing clinical presentations, provider bias, and system-level barriers such as follow-up challenges or diagnostic uncertainty.
Chlamydia and gonorrhea can present with a range of symptoms or be asymptomatic, which complicates timely diagnosis and treatment. While the Centers for Disease Control and Prevention (CDC) guidelines recommend empiric treatment in cases of high clinical suspicion, especially when patients may be lost to follow-up, the extent to which these guidelines are equitably applied across sexes remains uncertain.
Clinical Question: Are there sex-based disparities in the treatment of chlamydia and gonorrhea among adults presenting to US emergency departments?
Reference: Solnick et al. Sex Disparities in Chlamydia and Gonorrhea Treatment in US Adult Emergency Departments: A Systematic Review and Meta-analysis. AEM June 2025
- Population: Adults (≥18 years) presenting to US EDs with testing for chlamydia or gonorrhea.
- Exclusions: Pediatric patients, individuals with incomplete demographic or treatment data, and those not diagnosed in the ED.
- Exposure: Receipt of appropriate antibiotic treatment during the ED visit.
- Comparison: Male versus female patients.
- Outcomes: GC/CT positivity, empiric treatment rates, and discordance between treatment and test results stratified by sex.
- Type of Study: Systematic review and meta-analysis
Dr. Rachel Solnick
This is an SGEMHOP, and we are pleased to have the lead author on the episode. Dr. Rachel Solnick is an Assistant Professor of Emergency Medicine at the Icahn School of Medicine at Mount Sinai. Her research focuses on HIV prevention, STI care, and maternal health, with an emphasis on expanding access to high-quality reproductive and sexual healthcare for all emergency department patients. She is the PI of an NIH Career Development Award studying the implementation of HIV pre-exposure prophylaxis (PrEP) for ED patients diagnosed with STIs during telephone callbacks.
Authors’ Conclusions: “Significant sex-based disparities exist in ED empiric antibiotic treatment for GC/CT. Females were 3.5 times more likely than males to be potentially under-treated. These findings underscore the need for targeted interventions to reduce disparities and improve treatment accuracy. Interpretation is limited by study heterogeneity and incomplete sex-specific data.”
Quality Checklist for Systematic Review:
- The main question being addressed should be clearly stated. Yes
- The search for studies was detailed and exhaustive. Yes
- Were the criteria used to select articles for inclusion appropriate? Yes
- Were the included studies sufficiently valid for the type of question asked? Yes
- Were the results similar from study to study? No
- Were there any financial conflicts of Interest? None reported
Results: The included 19 studies comprised 32,592 ED patients who were tested for STIs and analyzed. The heterogeneity of the prevalence estimates had I2 values of 92.6% or higher.
Key Result: Female patients were much less likely to receive recommended antibiotic treatment compared to male patients, while males were much more likely to be over-treated compared to females.
- Among patients with laboratory-confirmed chlamydia or gonorrhea pooled estimate was 3.5 for females being under-treated relative to males.
We asked Rachel five nerdy questions. Listen to the SGEM podcast to hear her responses.
1. Chart Review: These often lack the granularity that can contextualize treatment decisions. For instance, the data may not include symptom severity, provider rationale, or specific patient-provider discussions about treatment. These missing nuances could explain some of the apparent disparities, such as if certain patients refused treatment or if providers made decisions based on clinical judgment not reflected in coding. This limitation introduces potential misinterpretation of the observed treatment gaps, particularly in distinguishing between provider omission and justified clinical discretion.
2. Risk of Bias: You used the Joanna Briggs Institute (JBI) Critical Appraisal Tool for cross-sectional studies to assess the methodological quality of studies included in your systematic review. This version of the tool includes eight domains, focusing on areas such as inclusion criteria, valid and reliable measurement of exposure and outcomes, and appropriate statistical analysis. Why did you select the JBI rather than the ROBINS-I (Risk Of Bias In Non-randomized Studies – of Interventions) for observational studies?
The overall assessment indicated that the included studies were at low to moderate risk of bias. Most studies received favourable assessments across most domains. However, concerns were raised in specific areas, particularly regarding the reliability of outcome measurement and management of confounding, which contributed to variability in the quality ratings.
3. High Heterogeneity: The heterogeneity in this study was 92.6% or greater, indicating considerable variability in study results beyond what would be expected by chance alone. This variability may stem from differences in study design, geographic regions, patient populations, ED workflows, diagnostic practices, or definitions of empiric treatment. While the authors used a random-effects model to account for between-study differences, such heterogeneity limits the precision and generalizability of the pooled estimates. It also complicates interpretation, as the aggregated results may mask important contextual factors that influence treatment disparities across different healthcare settings. Why not do a narrative review and not meta-analyze the data?
4. Confounding Bias Due to Unadjusted Estimates: The study did not adjust for any variables. Important factors such as sexual history, prior STI diagnoses, or socio-economic status may not have been fully captured or adjusted for. These unmeasured variables could influence both the likelihood of receiving treatment and the likelihood of infection, thus affecting the estimated association between patient sex and treatment rates. The presence of unaccounted confounders could either exaggerate or underestimate the true magnitude of the disparity.
5. Generalizability: The findings are drawn from studies that used data collected in specific health systems and regions, which may not reflect broader national practice patterns. None of the studies came from the western US or focused on patients from rural communities.
Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the authors’ conclusions.
SGEM Bottom Line: There is a high amount of UNDER-treatment (women>men) and OVER-treatment (men>women) in patients clinically diagnosed with chlamydia or gonorrhea in US EDs.
Case Resolution: You diagnose the 24-year-old patient with suspected chlamydia based on symptoms and epidemiologic risk. Despite a pending confirmatory test, the ED team adheres to CDC guidelines and provides empiric treatment. The patient is counselled on safer sex practices and linked to local STI follow-up services.
Dr. Suchi Datta
Clinical Application: EDs should consider guideline-based STI treatment protocols across all patient demographics. Clinical decision support and workflow optimization may help mitigate disparities and improve timely care for all patients.
What Do I Tell the Patient? I would do some shared decision making and say something like…You may have a sexually transmitted infection. If you’re not sure you will be able to come back to the ED for treatment or to get your results, then it’s reasonable to treat you today with antibiotics to make sure we don’t miss an infection. ”
Keener Kontest: Last week’s winner was David Pecora. He knew Peter Gabriel was the original lead singer for the band Genesis.
Listen to the SGEM podcast for this week’s question. If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.
Now it is your turn, SGEMers. What do you think of this episode on sex-based disparities in the treatment of STIs? What questions do you have for Rachel and her team? Post your comments on social media using #SGEMHOP. The best social media feedback will be published in AEM.
Other SGEM Episodes on STI:
- SGEM#104: Let’s Talk about Sex Baby, Let’s Talk about STDs
- SGEM#335: Sisters are Doin’ It for Themselves…Self-Obtained Vaginal Swabs for STIs
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