The paper by East et al. (2010) provides an interesting perspective on how women respond to having a sexually transmitted infection (STI) and sheds light on how they conceptualise risk to themselves and also how they epitomise the social perception that only certain ‘types’ of women get an STI. It fits very nicely with the work of Piercy (2006) for example in the description of how some women feel ‘dirty’ as a result of acquiring an infection from sexual activity.
However, for this commentary I would like to pick up on one aspect of the study that concerns the attitudes and actions of some of the women with regard to informing (or rather not informing) their sexual partners that they have an STI. In this respect, I was particularly drawn to this remark by the authors:
Although the women generally perceived themselves as responsible, some did not disclose their infection status and on occasions continued to engage in unsafe sexual practices after their STI diagnoses. (Leah et al. 2010, p. 1998)
This is a very interesting element of sexual health and is worth exploring and placing in the context of sexual health nursing and the wider ethics of sexual public health. To do that, imagine that this intention is disclosed in a sexual health clinic to a nurse. Of course, the immediate response would be to counsel the woman that this could put her at risk of further infection and that it is important that partners are made aware of any infection they could have contracted to obtain treatment themselves. Good sexual health practice would then dictate that the clinic could help the woman explore strategies to inform a partner – or even get involved in doing it themselves. All well and good – but what if a client refuses to inform a sexual partner that she has an STI – what then?
This scenario raises a number of professional, legal and ethical issues that have been discussed before in the context of HIV diagnosis and disclosure (Hayter 1997), and although STI’s do not carry the same weight as a HIV diagnosis, the issues are the same. If a professional knows a patient has an infection, is aware of that infection and that the client intends to put others at risk how should the practitioner respond? In effect, this issue becomes one where client confidentiality clashed with the wider public health and duty of care to others. Let’s assume that the sexual health clinic knows the identity of the woman’s sexual partner and attempts to persuade her to inform her partner have failed. Do they tell him about his female partners STI if she won’t or not?
In favour of not disclosing is the concept of confidentiality – a precious commodity for sexual health services. If a clinic is known to disclose client information, this could affect the decisions of others to use that service – thereby defeating the public health defence of the decision to disclose on the grounds of preventing infection. Why should the onus to inform be on the individual with the infection whilst leaving those ignorant of their STI status in the clear? In respecting client confidentiality, the clinic is putting their client first and reinforcing the privacy of their service.
However, the argument to disclose to an unwitting sexual partner is equally compelling. As a practitioner and a clinician, there is surely a duty of care to this person to make them aware of the risk. If the infection was HIV then the index client may well be committing a criminal offence by knowingly exposing a partner to HIV – making any professional who supports this non-disclosure an accessory? This hasn’t been tested in any court, but I am sure it will be. The UK and the USA have both prosecuted and imprisoned individuals for infecting partners with HIV and until now the professionals involved in their care and possibly aware of their actions have escaped attention by the courts.
There are some who argue that laws to compel the disclosure of HIV status to prospective sexual partners should be extended to other STIs – but this is a matter for another, longer discussion. Nevertheless, what this issue indicates is that confidentiality does have its limits and as health professionals we should be aware of this and accept it.
No one would argue that information disclosed by a patient to a nurse about a bomb placed in a station should be respected as confidential (at least I hope not) and similarly none would argue with the importance of keeping information about a patients haemorrhoids confidential. The first situation is one where the public interest to disclose is clearly paramount – the second has no public interest disclosure case to be made. Unfortunately, confidentiality, public interests and sexual health are not usually as clear cut as this. The decision by some clients to place others at risk of an STI finds itself in a much greyer area of the public interest versus confidentiality field.
From my perspective, I tend to favour the disclosure to the partner at potential risk – but only if all attempts to persuade the client to disclose have failed. First, I think it is the morally right thing to do; and second, I would rather defend breaching confidentiality in this kind of situation than defend a charge of failing in my duty of care to the person infected as a result of my inaction. However, I am certain that many practitioners would take a different view.