Fear of stigma and rejection can lead to non-disclosure of STI status

In a recent review article published in the Journal of Sex Research, researchers explored the existing literature on sexually transmitted infection (STI) disclosure, highlighting the emotional complexities and strategies involved in the disclosure process.

They concluded that relationship factors significantly influence disclosure decisions. Still, there is a need for more research on the experiences of those receiving STI disclosures to inform future education and intervention efforts better.

Study: Disclosure of Sexually Transmitted Infections to Sexual Partners: A Systematic Critical Literature Review. Image Credit: Tutatamafilm/Shutterstock.com

Background

In 2018, the Centers for Disease Control (CDC) estimated that 67.6 million people in the U.S. had an STI, with 26.2 million new cases reported that year. Emerging adults (ages 18-29) are most at risk and concerned about contracting STIs.

Since STI rates have remained high and continue to rise, especially amid the coronavirus disease 2019 (COVID-19) pandemic, a review of STI disclosure literature is timely and necessary. The CDC recommends various STI prevention methods, including disclosure to sexual partners.

However, existing research on STI disclosure often lacks guiding frameworks and robust methodology and frequently excludes the perspectives of disclosure recipients. Fear of stigma, relationship quality, and symptoms are all factors that are known to influence the decision to disclose one’s STI status.

Methods

This review aimed to systematically and critically evaluate STI disclosure research using the Health Disclosure Decision-Making Model (DD-MM), identify research limitations, propose future research directions, and offer insights for sexual health education, practice, and policy.

The DD-MM framework was chosen for its comprehensive approach to health-related disclosures, focusing on information assessment, receiver evaluation, and disclosure efficacy. An important objective of the review was to enhance the DD-MM to address the complexities of STI disclosure.

The researchers conducted a systematic critical literature review (SCLR) using methods modeled after previous research and followed a clear and replicable strategy that involved four steps.

This included identifying relevant peer-reviewed articles from medical and scientific databases, screening abstracts, examining full texts, extracting data, and conducting critical appraisal and article analysis.

Results

The review included 32 studies on STI disclosures, with a mix of quantitative (34.4%), qualitative (46.9%), and mixed-methods (18.7%) research. The studies varied in design, with cross-sectional being the most common for quantitative and mixed-methods studies, while Grounded Theory was frequently used in qualitative research.

Most studies were conducted in the US, and convenience and purposive sampling were used often. The studies included predominantly White samples with broad age ranges that precluded disaggregating findings for emerging adults.

Thematic synthesis revealed several key themes aligning with and expanding on the DD-MM model, particularly regarding feelings about disclosure, reasons for and against disclosure, and strategies used.

Emotions like fear, anxiety, guilt, and anger were prominent, with fear being the most common, often related to anticipated negative partner reactions.

Despite negative emotions, many disclosed their STI status due to beliefs in honesty, moral obligations, concern for their partner's health, and maintaining relationship integrity.

Conversely, non-disclosure was often driven by fear of emotional and behavioral reactions, rejection, and beliefs that disclosure was unnecessary in casual relationships. Some also cited privacy, shame, and logistical barriers as reasons for non-disclosure.

Strategies for disclosure included priming messages, direct approaches, and framing the STI differently, while non-disclosure strategies included "passing" as uninfected, slowing relationship progression, or timing sexual activity based on symptom presence.

Disclosure timing varied, with many believing it should occur before sexual activity, though actual practices varied. Relationship factors played a significant role, with disclosures more likely in committed, long-term, and high-quality relationships. Transitions in relationship commitment levels often triggered disclosures.

While the DD-MM was useful, the review highlighted its limitations and the complexity of STI disclosure decisions influenced by emotional, relational, and situational factors.

Conclusions

This review systematically examined the literature on STI disclosure, identified gaps, and suggested enhancements to the DD-MM. The analysis revealed that past studies are largely qualitative and lack a theoretical basis.

The authors recommend augmenting the DD-MM with considerations of pre-diagnosis beliefs, diagnosis-related emotions, and self-assessment processes, which play crucial roles in disclosure decisions.

Additionally, the nature and milestones of relationships significantly influence disclosure, prompting suggestions to expand the model to include these factors.

The review identifies methodological improvements for future research, emphasizing the need for diversity in sample populations and better demographic reporting, including sexual orientation and gender inclusivity.

Further research should also focus on the experiences of disclosure recipients and relationship dynamics. Distinguishing between “disclosure” and “partner notification” is essential for clarity in research.

Educational and intervention implications include the need for comprehensive sexual health education and counseling to improve disclosure efficacy. Addressing misconceptions about STI transmission and enhancing practitioner-patient interactions can foster better disclosure practices. The review highlights the need for destigmatizing sexual health conversations and addressing health inequities that impact disclosure.

The study’s limitations include excluding HIV disclosure literature, potential biases from using the DD-MM framework, and restricting English-language publications.

Despite these, the findings offer valuable insights into STI disclosure processes, underscoring the need for continued research and improved educational and intervention strategies.