Picture this: One of your regular patients presents to you with unusual symptoms suggestive of chlamydia, which is later confirmed by lab tests. Complicating matters is the fact that the patient's wife is also a patient of yours. The patient requests you not reveal this information to his wife. So, what should you do?

This dilemma poses an ethical question: Should you break patient confidentiality and inform the wife about her potential exposure to a sexually transmitted infection?

 

Patient confidentiality vs ethical obligation

 

Confidentiality is a cornerstone of the physician-patient relationship, enshrined in the Hippocratic oath. However, it is not without bounds.

Jane M. Grant-Kels, MD, FAAD, a pioneer in dermatoethics and the founding chair emeritus of the Department of Dermatology at the University of Connecticut, spoke with MDLinx about the tension between patient confidentiality and the potential harm to intimate partners. “It is a problem, because who do you owe your ethical obligation to: the patient or their potential contacts? The reality is, you owe it to both,” Dr. Grant-Kels says.

The patient’s autonomy and confidentiality are obviously very important, but it doesn't supersede your obligation to other people.

“The ideal thing is to try to have an open, transparent discussion with the patient and convince them to be the one to contact their contacts,” she continues.

 

The duty to warn

 

 

This concept is rooted in the landmark case of Tarasoff vs Regents of the University of California, where a psychologist was deemed liable for not warning his patient's girlfriend of the patient's intention to harm her, as she was maintaining physician-patient confidentiality.

Laves R. Tarasoff vs The Regents of the University of California et al - The mental health worker as expert in the prediction of violent behavior. US Department of Justice. Office of Justice Programs. January 1979.

 

 

Reporting and investigating STDs

 

In the United States, all diagnosed cases of HIV, chlamydia, syphilis, gonorrhea, and chancroid must be reported to the health authorities, as noted by authors writing in Clinics in Dermatology.

Parashar K, Grant-Kels JM, Korman AM. Doctor, please don't tell my partner I have a sexually transmitted disease. Clin Dermatol. 2023;41(2):289–290.

You should inform your patients that reporting their disease is legally required. 

 

 

“It would be best if you can be a resource for your patient,” Dr. Grant-Kels advises. “Guide them on how to explain this to their spouse, and also be a resource to their spouse, who is likely to become confused and upset.”

According to the CDC, most state health departments also utilize partner services like contact tracing and partner notification as essential measures to prevent the spread of STDs, especially in cases involving syphilis and HIV. 

 

Reporting other viral STDs

 

For other, more minor STDs, such as genital warts and genital herpes, there are currently no reporting guidelines. However, according to the Clinics in Dermatology authors, these infections “should also be ethically reported to intimate partners for their beneficence and to avoid maleficence, as some of these STDs can precipitate malignancy (genital warts), and others can result in painful recurrences that could be mitigated with appropriate medical intervention.”

Dr. Grant-Kels tells MDLinx, “It becomes a little bit trickier when it's not legally required for you to report an STD, but the patient theoretically has a moral and ethical obligation to notify their contacts. Again, the best route would be to guide the patient and convince them that the right thing to do is to notify all their sexual contacts.”

 

If you are a physician in California, and your patient cooperates, you can ask to examine and treat the third party (contact). At the same time, you can report the third party’s “suspected case” to the health department if there is no evidence they received treatment within 10 days.

In Indiana and Nebraska, if a patient identifies a third-party exposure, you must report it to the health authorities.

 

Expedited Partner Therapy

 

Expedited Partner Therapy (EPT) is a method whereby patients diagnosed with chlamydia or gonorrhea receive medicine to give to their partners, skipping the need for the partner to see a doctor at all.

The CDC states that EPT is particularly useful for managing male partners of women with STDs and offers great benefit when resources are limited.

Expedited Partner Therapy. CDC. April 19, 2021.

Currently, EPT is legal in 46 states.

Legal Status of Expedited Partner Therapy (EPT). CDC. April 19, 2021.

 

 

STI in very young children

 

Sexually transmitted infections in children beyond the newborn stage strongly suggest that they may have experienced sexual abuse.

“If you're suspicious that there's been sexual abuse to the child, you absolutely have to report and pursue it,” Dr. Grant-Kels emphasizes. “You can't take somebody's word for it. It has to be investigated by professional investigators.” Experienced clinicians trained in child abuse assessment should guide the investigation.

Sexual Assault or Abuse of Children. CDC. July 22, 2021.

 

 

Even in cases where child abuse remains unproven but is suspected, Dr. Grant-Kels stresses, “You absolutely have to ensure that nothing bad is going on. Otherwise, the damage done to the child [...] could go on for years and become unrepairable.”

 

Guidelines for adolescents

 

All US states and Washington, DC, explicitly permit minors to consent to STI services. However, 11 states require minors to reach a certain age (usually 12 or 14 years) before they can give consent.

In 32 states, HIV testing and treatment are included in the STI services that minors can consent to. In 18 states, doctors can inform a minor's parents that the minor is seeking or receiving STI services, if they believe it's in the minor's best interest. Still, except for one state that requires parental notification for positive HIV tests (Iowa), no state mandates parental notification for these services.

Minors’ Access to STI Services. Guttmacher Institute. September 1, 2023.

You can find state-by-state guidelines at this link.