STDs Expert Forum
Duty to Disclose
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The STD Forum is intended only for questions and support pertaining to sexually transmitted diseases other than HIV/AIDS, including chlamydia, gonorrhea, syphilis, human papillomavirus, genital warts, trichomonas, other vaginal infections, nongonoccal urethritis (NGU), cervicitis, molluscum contagiosum, chancroid, and pelvic inflammatory disease (PID). All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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Duty to Disclose

Dr.:

Again, thank you for this service.  

I have a question regarding the duty presumed to exist for people with genital herpes to disclose their status.  You write in the frequently asked questions section that the reason for this duty is because no combination of methods to prevent transmission work perfectly, and therefore those with genital herpes have a duty to disclose their status to sex partners, even when those sex partners do not inquire as to their status.  

This confuses me for many reasons.  First, it seems that the problem with genital herpes is its social stigma, which (however real) is only corroborated by treating it substantially differently than oral herpes, a difference which I take to be predominantly location based and (but for complications with child-birth) indistinguishable beyond that.  If there is no duty to disclose for oral herpes, why is there for genital herpes?  I'm unclear on how the presence of herpetic legions on the mouth are significantly less dangerous in the transmission of other diseases than the presence of such legions on the genitals, particularly given the use of oral sex, or that the regimes to prevent transmission of both hsv1 and 2 are significantly more effective for oral herpes (immunizing the need for disclosure) than for genital herpes.

I guess my confusion rests in the disparity with which the two strains are treated.  Because I think the disparity exists in large part due to stubborn puritanical notions about sex, I find a duty levied on people with genital herpes unpersuasive if the same does not exist for those with oral herpes. Am I missing something in thinking about the disparity?

Perhaps you can inform me as to the reasons for why you think there is a duty for genital herpes but not for oral herpes...

I also posted a while back inquiring about the prevalence statistic among MSM, to which you responded that it is at least 50% if not 50-70%.  Such a prevalence rate suggests that the reasonable burden of a herpes discussion rests with the person who is attempting to avoid the infection.  It seems counter-intuitive to impose a duty of disclosure on someone with herpes, when the question about their status isn't posed, and the prevalence in the community is above 50%.  Does this make sense? I'm mindful that this sounds like rationalization, but, to me, the duty to disclose is based on no more solid ground.

In my experience, I've found it interesting talking about herpes with MSM, because they either already have it, or tend to know its prevalence rate and so assume they have it.  

I realize this is a disorganized post, but I'd definitely appreciate any thoughts you had about the duty to disclose unsolicitedly (not the duty to answer, when asked, truthfully) for people with genital herpes, especially in, say, the MSM community, which exhibits such high prevalence of HSV2.
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The duty to warn partners, when a person has a chronic, potentially transmissible STD, is not absolute and people need to make their own judgments.  Some readers disagree and think the duty is absolute, and I cannot say they are necessarily wrong.  Ethics annd morality are not hard sciences.  In other threads, I have sometimes given my own perspectives on herpes and other STDs.  On balance, most experts (both medical and ethical) believe that if there is any reasonable chance of transmission of HSV, there is a duty to disclose the risk to partners.  You absolutely are right about the stigma associated with genital vs oral herpes, which influences my personal opinion about the relative importance of disclosing one's HSV-2 vs HSV-1 infection.

I cannot tell you why, biologically, HSV-1 is less associated with HIV transmission than HSV-2.  Undoubtedly it is related to the dominance of HSV-2 as an anogenital infection and HSV-1 as oral; and when HSV-1 is genital, it reactivates less frequently than HSV-2.  Oral exposure and oral-genital HIV transmission are so uncommon anyway that any increased risk possibly associated with HSV-1 may just be too small to measure.

The notion that just because lots of people are infected they do not have a duty to disclose--that the entire burden of prevention rests with those exposed to such people--seems to me to be morally bankrupt.  I suppose if the carriage rate were truly 100%, that philosophy might apply.  But certainly not at 50-70%.  I do not understand how a person can put another person at signficant risk for harm (as defined by the recipient, not the infected carrier) without the exposed person being given the opportunity to know the risk and decide whether or not to take the risk or to take precautions against infection.

Aside from the ethical question, there is a very practical issue:  relying on uninfected people to protect themselves has failed miserably as an HIV prevention strategy.  That was the main emphasis of public health recommendations for HIV prevention in the US for almost 2 decades.  Its abject failure is one reason why there is now dominant emphasis on people knowing and disclosing their HIV status to potential partners.  (The other reason, of course, is that life-prolonging therapy is now available, so there is personal as well as prevention benefit in being diagnosed.)

I see no logical reason to not apply the same principles to HSV-2.  Obviously it's not nearly as serious as HIV (except to the extent it increases the risk of HIV transmission). But genital herpes remains the single STD aside from HIV that frightens sexually active people, still substantially outweighing HPV.  It doesn't matter that much (most?) of the fear is about the stigma and psychological consequences; as I said above, the person at risk gets to define how big a deal it is for them.

Regards--  HHH, MD
5 Comments
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In re-reading my response, I wasn't very careful in wording the opening sentence of paragraph 3.  Please be assured I'm not accusing you of being morally bankrupt!  You raised thoughtful questions in a thoughtful manner, and that is how I intended to respond.  Poor choice of words--maybe OK at a philosophical level, but not to be taken personally.

Regards--  HHH, MD
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Thanks Doctor,

I appreciate your comments, and (don't worry) I didn't take offense.  

I understand from a strategy point of view encouraging HSV2 positive folk to disclose. But, if we're to talk about burden shifting before disclosure, what I meant to say above is that while the burden to ask about STD status rests with both parties and the burden to be honest is absolute, if neither party asks, I am still confused as to why there is an burden on the infected party to be affirmative with that information.  Again, while it seems like a reasonable thing to encourage the herpes positive community to adopt, it also seems to fall short of a duty in my mind.  Essentially, if the reasons for why herpes should be disclosed are the stigma attached to it by society, and the fear it cultivates in the sexually active community, then it seems more reasonable to place the burden of asking about STDs on parties that are so tremendously afraid, not on parties who find herpes either not terrifying at all or irrelevant.

Just curious.  I realize this is not an issue of clear morality, particularly when sexual practices imply a whimsy toward STDs that may not exist when folks are sober of desire.  Still, if we're thinking of how/who/what to incentivize, I often wonder if incentivizing people who would typically be afraid of an STD to ask, v. people infected with an STD to disclose, may incentivize a better and more regularly manageable standard.  

Cheers,

Herps2005
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Your comments are thoughtful.  At a personal level, it still seems to me that basic ethical considerations require an infected person to affirmatively disclose any known sexually transmissible infection to a partner before having sex.  The anticipation of sexual gratification has to be secondary.  "Before we start, you should know that I am HSV-2 positive.  Most likely I'm not infectious right now, but I wanted you to know."

For public health policy, however, human nature being what it is, I know that many infected people will not disclose.  And most infected people don't know it anyway--so at a population level (as opposed to the personal one) proactive disclosure may not make much difference in the number of people who catch HSV-2 (or HIV as a result of HSV-2).

My bottom line is that both approaches are necessary, because one size does not fit all.  HSV-2 infected people should disclose; but I would not (and do not) insist on it with the same intensity as for HIV (for which I believe there is little if any middle ground).  And recognizing that many HSV-2 infected people will not do so, people who are particularly concerned about herpes should ask.

HHH, MD
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Is the >50% prevalence of HSV2 infections cited for the MSM community from a (scientific) study or is this rate presumed based on anecdoctal evidence?  I was at a lecture given by a local MSM STD prevention organization and they listed the 25% rate,  It seems if the rate is twice or higher, it shold be listed.
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