We appreciate the commentary provided by Hayter (2010) and the contention surrounding sexual health ethics and, specifically, the non-disclosure aspects among individuals who have an STI that Hayter refers to. The clinical application of our work, as discussed by Hayter, illuminates the dilemmas that can be associated with the need to maintain patient confidentiality (in relation to non-notifiable diseases) and health risks to the wider population. In the clinical arena, many sexual health clinics have implemented procedures, such as contact tracing, to assist individuals in disclosing infections to sexual partners, whilst remaining relatively anonymous. However, such methods are reliant on patients providing accurate information about their sexual history.
Although Hayter (2010) raises the dilemma healthcare professionals may face in choosing to disclose an STI to a partner of a patient, which could breach patient confidentiality, any possibility for such disclosure is still reliant on patients revealing the identity of sexual partners. Gaining this information can be hindered by stigma and the dynamics of sexual relationships, particularly within the context of casual and unplanned (or unintended) sexual encounters. The presumption that patients will be honest in conveying whether they have disclosed their infection to previous and current partners may be limited because of patients conveying simply what they perceive the clinician wants to hear, or what they consider socially acceptable to divulge. Further, whilst somewhat understandable, Hayter’s suggestion to disclose sensitive information to a partner (albeit as a last resort) may serve as a barrier to honesty regarding patient disclosure to clinical staff.
Unlike clinical staff, researchers are not in a counselling or therapeutic role with clients and are bound by confidentiality. As researchers, nurses are strictly governed by the confidentiality requirements of institutional ethics committees, who do not generally have a ‘need to know’ clause, which is an escape clause through which disclosure can sometimes be made without the client’s consent. Indeed, in this study (East et al. 2010a), where data were computer assisted, participants were completely anonymous and thus further disclosure or reporting was impossible. Further, to attempt to counsel or advise participants regarding the consequences of their decisions related to disclosure would have meant stepping outside the boundaries of the researcher role.
As nurse researchers, we need to reflect on our position when we are undertaking research, particularly on sensitive issues; however, decisions around this are not always straightforward. Nurse researchers have raised these issues, and over the years have since Borbasi (1994) and Rudge (1996) highlighted these concerns, the issues remain contentious and challenging. As highlighted by these authors, real tensions can exist between the roles of researcher and nurse. To gain new and valuable insights into a phenomenon, particularly one that is shrouded in stigma and social undesirability, researchers need to position themselves clearly as a researcher (rather than as a nurse or therapist). To take the stance of ‘health professional’ in some cases could jeopardise the level of participant disclosure and could affect the quality and therefore usefulness of the data collected to inform strategies for change.
The purpose of research into these aspects of human experience is to raise awareness of hidden issues around how people assimilate the information they are given by health professionals and how they then act on it in their everyday life. In making these largely hidden aspects of life visible and in presenting insights into why individuals make certain choices in certain situations, we realise that we present real dilemmas for the health professions. However, without such visibility, the issue of non-disclosure may not be adequately addressed by clinical practitioners. Therefore, to gain accurate information about health care practices, it is essential to provide an environment in which patients feel safe to share. Research that ensures anonymity (such as we did in this particular study) and, therefore, enhances participants perceived safety to convey details of their sexual lives and sexual health practices provides truly valuable insights into these behaviours. Valuable information such as this has the potential to affect real change in the ways in which we support, counsel and educate patients.
In this study (East et al. 2010a), there were many reasons that some of these particular women (on occasions) chose not to disclose having an STI to partners. These included the powerful role of denial even in the face of medical evidence; a refusal to believe they had an infectious condition or that they had taken steps to mitigate their condition, so that they believed they posed no threat, and therefore did not disclose. Although other researchers have highlighted the reluctance to disclose, having an STI is common among both men and women (Morgan et al. 2001, Kahn et al. 2005), what our paper reveals is some insights into why these women were reluctant to disclose. It is these insights that can provide the basis for relevant and effective strategies that may be implemented to address the issue of women’s non-disclosure. As we mention in our paper, the promotion of positive coping strategies may serve to instil in women the confidence they require to disclose their STI status (East et al. 2010a). Whilst we cannot make generalisations based on this work, we can report that these women experienced a sense of vulnerability that affected their decisions around disclosure to partners. We have argued elsewhere (East et al. 2010a) that the very act of disclosure in the presence of an accepting and respectful listener could assist in developing personal resilience, reduce vulnerability, and thus empower them to feel safer to disclose such sensitive information.