Reducing racial/ethnic disparities in Chlamydia trachomatis (CT) infections among adolescent and young adult (A/YA) females is an important sexual health priority. In 2023, the rate of reported CT cases among non-Hispanic Black (Black) females aged 15–19 years was more than five times the rate among non-Hispanic White (White) females in the same age group (6,248.1 vs. 1,114.5 per 100,000 women) (1). A similar disparity existed in females aged 20–24 years (Black: 6,736.8 vs. White: 1,575.5 per 100,000 women; rate ratio: 4.3), and rate ratios in both age groups have remained stable over the past decade (2). CT case reports are sensitive to changes in diagnostic, screening, and reporting practices and are limited in describing the individual or societal level factors contributing to the transmission of these infections across racial/ethnic groups. To gain a more complete understanding of factors associated with racial/ethnic disparities observed in CT case rates among female A/YA, it is important to estimate racially stratified CT infection prevalence and its associated correlates.

CT screening practices vary significantly among A/YA females by race/ethnicity. Despite similar levels of lifetime sexual activity (3), higher levels of CT screening among Black and Hispanic compared with White A/YA females point to racial/ethnic inequities in screening practices performed by healthcare providers (4) that can impact observed CT morbidity. Similarly, previous studies have extensively documented individual and societal-level factors that act as barriers to sexual and reproductive health (SRH) care among A/YA females (5–7). These factors include cost, limited access to and utilization of SRH services, and concerns related to confidentiality, which can be exacerbated by experiences of racism within the healthcare system (8). Such barriers can significantly impede the timely detection and treatment of CT infections, which often manifest without apparent symptoms. Additionally, heterogeneity in individual-level sexual behaviors by race/ethnicity among A/YA can affect CT prevalence (9). National-level trends have been mixed for many years in terms of the behavioral factors that increase STI risk among A/YA females that directly affect the probability of acquiring CT infection. From 2013 to 2023, data from the Youth Risk Behavior Survey (YRBS) show reports of fewer sexual partners among female high school students, particularly among Black A/YA (3). However, trend analyses from the National Survey of Family Growth (NSFG) among female youth aged 15–19 years from 2008 to 2019 did not identify similar changes (10). Both sources indicated a decline in condom use among A/YA across all racial/ethnic groups (3) and specifically among Black females (10) during this period, which may have contributed to racial/ethnic disparities in CT rates, particularly among those engaging in other sexual risk behaviors (e.g., alcohol or drug use before sexual intercourse) (11).

Previous population-based assessments of CT prevalence using data from the National Health and Nutrition Examination Survey (NHANES) pointed to differences by race/ethnicity but did not focus specifically on A/YA females or consider prevalence differences by behavioral factors that increase STI risk (12, 13). Updated national reports of CT prevalence by race/ethnicity among A/YA females are crucial for informing local screening and prevention efforts. To address this gap, we analyzed data from the 2011–March 2020 cycles of NHANES to estimate CT prevalence and associated behavioral factors that increase STI risk among A/YA females stratified by race/ethnicity.

The analysis included an unweighted sample size of 1,669 sexually experienced A/YA females. White females had the highest percentage reporting health insurance coverage (86.3%, 95% CI: 82.8%–89.7%), followed by NHO (82.3%, 95% CI: 75.0%–85.6%), Black (79.8%, 95% CI: 75.8%–83.8%) and Hispanic females (71.1%, 95% CI: 66.4%–75.8%) (Table 1). A higher percentage of Black females reported ≥2 partners in the past year compared with females in other race/ethnic groups (Black: 37.7%, 95% CI: 33.4%–42.0% vs. White: 32.6%, 95% CI: 29.1%–36.2%; NHO: 26.8%, 95% CI: 18.5%–35.2%; Hispanic: 22.0%, 95% CI: 17.7%–26.4%), though not all differences were statistically significant. The overall percent of A/YA females who reported not using a condom during sex in the past year was 78.9% (95% CI: 75.6%–82.0%) and did not vary significantly across racial/ethnic groups.

Among A/YA females who underwent urine CT testing (n=1,652), overall CT prevalence was 5.8% (95% CI: 4.5%–7.3%) (Table 2). CT prevalence was higher among Black females than the average of the other groups (vs. Hispanic, NHO and White) (11.7%, 95% CI: 8.7%–15.2%) and lower among White females (vs. Black, Hispanic and NHO) (3.2%, 95% CI: 1.7%–5.5%). CT prevalence was 10.3% for NHO (95% CI: 3.5%–21.9%) and 6.7% for Hispanic (95% CI: 4.4%–9.7%) females and did not vary significantly when compared with the average prevalence among females in the other three racial/ethnic groups.

Among females with health insurance, CT prevalence was 10.5% for Black females (95% CI: 7.4%–14.3%) and 3.4% for White females (95% CI: 1.6%–6.2%). A similar pattern of CT prevalence was seen among Black and White females without health insurance (Black: 16.2%, 95% CI: 8.1%–27.7%; White: 2.4%, 95% CI: 0.2%–8.9%). Among females with 0/1 partner in the past year, CT prevalence was higher for Black females (vs. Hispanic, NHO and White) and lower for White females (vs. Black, Hispanic and NHO) (Black: 8.9%, 95% CI: 5.1%–14.4%; White: 2.3%, 95% CI: 0.7%–5.4%). Comparatively, CT prevalences among those with ≥ 2 partners in the past year were close to double (Black: 16.1%, 95% CI: 10.9–22.5%;) or more than double (White: 5.2%, 95% CI: 1.9–10.8%) those with only 0/1 partner in the past year.

Controlling for all covariates in multivariable analysis, Black female A/YA had a CT prevalence that was 2.5 times as high as the average CT prevalence of Hispanic, NHO, and White females (95% CI: 1.6–3.8) (Table 3). From the same comparisons, CT prevalence was significantly higher for Black females with health insurance (APR=2.2, 95% CI: 1.3–3.5), for those without health insurance (APR=3.4, 95% CI: 1.5–8.0), and for those with ≥2 partners in the past year (APR=3.0, 95% CI: 1.7–5.3). CT prevalence was also significantly higher among Black females (vs. Hispanic, NHO and White) who reported not using a condom during sex in the past year (APR=2.4, 95% CI: 1.5–3.9) and lower among White A/YA females (vs. Black, Hispanic and NHO) who reported not using a condom during sex in the past year (APR=0.3, 95% CI: 0.1–0.6).

During 2011–March 2020, Black (vs. Hispanic, NHO and White) and White (vs. Black, Hispanic and NHO) A/YA females had the highest and lowest prevalence of CT compared to the average CT prevalence of the other race/ethnicities. Notably, our analysis shows that Black females had a higher CT prevalence than the average CT prevalence of Hispanic, NHO and White females regardless of whether they currently had health insurance. This difference may be due to inconsistent and disparate use of SRH services among racial/ethnic minority youth. Previous studies have found that Black A/YA females were more likely to report being offered preventive SRH services, such as STI testing and having discussions with healthcare providers about sexual health, than their White counterparts (15–17). Although it is encouraging that Black A/YA females report receiving SRH services and having conversations about sexual health with healthcare providers, they often report experiencing stigma, discrimination, and discomfort during these interactions (18). There continues to be a lack of adherence to clinical guidelines for including SRH topics in discussions between healthcare providers and A/YA patients during clinical visits (19) that may be contributing to reports of these negative healthcare experiences. Moreover, studies examining racial/ethnic differences in the receipt of SRH care among A/YA females only reflect the reports of those actively seeking SRH services and do not represent the experiences of those who forgo care due to a lack of trust in providers, fear of judgement, and concerns related to confidentiality (20).

We also found that CT prevalence among Black A/YA females was higher compared with the average CT prevalence of Hispanic, NHO and White females regardless of the number of sex partners in the past year, although, in adjusted analyses, this effect only remained statistically significant among those with ≥ 2 partners. CT prevalences among A/YA not using condoms was also higher than average among Black female A/YA (vs. Hispanic, NHO and White) and lower than average among White females (vs. Black, Hispanic and NHO). These findings reinforce longstanding evidence that factors related to sexual networks may play a more significant role in the racial disparities of STI prevalence than individual-level STI risk factors (21–23). Although we included several individual-level behaviors that have potential for increased CT transmission, data on partner-level characteristics that are associated with the acquisition of STIs, such as concurrency (i.e., being in more than one sexual relationship at the same time), were not collected in NHANES. Additional studies that include both individual and partner-level STI behavioral factors that increase STI risk by race/ethnicity, sex, and age may generate additional insights into which factors contribute most to racial/ethnic disparities in CT prevalence among A/YA.

Our analyses are subject to other limitations. First, the prevalence estimates among A/YA females presented here do not include CT infections at non-genital anatomic sites that can be infected through sexual contact, such as the rectum and oropharynx. Thus, the prevalence estimates presented are likely an underestimate of the actual burden of CT infection among A/YA females in the general population. Second, small sample sizes of A/YA females testing positive for CT infection resulted in estimates with wide CIs. Our analytic sample only included A/YA females within the age range recommended for annual screening (<25 years) and numerators were small, particularly when stratified by race/ethnicity. Also of note, the percentage of missing data on condom use in our analytic sample ranged from 10% (White) to 18% (NHO) among A/YA females. Reports of condom use among A/YA are lower among females than males which may be due, in part, to the use of other contraceptive methods to prevent pregnancy (24). Lastly, the data utilized were cross-sectional, which may have obscured trends in CT prevalence as well as trends in behavioral factors related to STI risk during this period.

In our analysis, a higher CT prevalence was most apparent for Black A/YA females compared with the average CT prevalence of Hispanic, NHO and White females. Additional research incorporating sexual network-level measures is needed to explain CT prevalence differences by race/ethnicity, considering previously observed inconsistencies in behavioral factors that increase STI risk among A/YA over the past decade (i.e., fewer sex partners, lower condom use). Expanding access to high-quality, low-cost, and confidential SRH services among racial/ethnic minority youth remains crucial for reducing disparities in the burden of CT nationwide.