Few issues in health care arouse as much controversy as those associated with sexuality and sexually transmitted diseases (STDs). The prevention, diagnosis, and management of sexually transmitted diseases impacts individual patients and families, as well as the population as a whole. Politics, schools, the media, and public health systems all influence policies about STDs. This month Virtual Mentor explores some of the ethical issues surrounding STDs, such as confidentiality, stigma, and the exchange of information between physician and patient. Though some clinicians may be uncomfortable with this topic, STDs are not rare and can impact almost any age group or segment of the population.
We begin this issue with 3 clinical cases. In the commentary on the first case, David Cundiff illustrates strategies for managing a patient's request for confidentiality at the time a STD diagnosis is made. In Case 2, Ligia Peralta and Kathryn Conniff, as co-authors, and Christopher Kodama provide 2 perspectives on appropriate documentation of sexual risk factors in a patient's chart and address what is and is not clinically relevant information. In Case 3, Leslie Wolf explores how a medical student can address stigma about STDs when it is encountered in the hospital. These are scenarios that could happen in any hospital or clinic.
The clinical approach to STDs begins with taking a patient's sexual history. Many clinicians are uncomfortable with taking a detailed sexual history, and some even choose to avoid asking these personal questions, instead making assumptions based on the patient's age or socioeconomic status. In medical education, Ponrat Pakpreo reviews the importance of taking a thorough sexual history and lists its essential elements.
The diagnosis and management of STDs are continually evolving as new research discoveries are made. In a journal discussion, Abraham Schwab reviews a recent article by Matt Golden and Lisa Manhart that examined the advances in STD diagnosis and treatment. Jeffrey Klausner addresses the process by which emergent research leads to health policy changes in this month's policy forum, using the example of partner-delivered therapy for infections caused by Chlamydia trachomatis.
STDs affect individual patients, but they also impact populations. The prevalence of STDs within a population is affected by both demographic and cultural factors. Sevgi Aral explores these fascinating links in discussing the demographic transitions that contributed to the sexual practices of today. Laura McGough's medical humanities article illuminates the impact of stigma, a cultural force dating back hundreds of years, on STDs. In the health law section Laura Lin and Bryan Liang grapple with the sometimes competing values of confidentiality, protection against discrimination, duty to warn, and protection of public health.
Prevention of STDs is a desired goal of patients, families, schools, and physicians. There is no consensus, however, from these diverse groups, about how best to direct efforts toward this goal. At present, the role of schools in prevention of STDs and teen pregnancy is a topic of much controversy. Advocates for abstinence-only and comprehensive sex education are both convinced that their methods provide superior prevention. In the medicine and society section of this issue, teacher Robynn Barth describes her own experiences "in the trenches," teaching sex education in a rural middle school. Joe McIlhaney and Debra Hauser discuss pros and cons of abstinence-only education in schools, providing the 2 sides for our op-ed section.
Finally, a concern of almost all 3rd-year medical students beginning their clinical clerkships is the fear of sustaining a needlestick and subsequently contracting a STD or bloodborne illness. In the clinical pearl article, Josiah Penalver reviews the actual prevalence of this rare occurrence, the diseases associated with needlesticks, and the appropriate measures to pursue in the event of a needlestick injury.
Our hope is that this issue will provide readers with an ethical and historical grounding in issues concerning the care of patients with STDs. We also hope this month's VM will offer readers an increased appreciation of the balance between patient and population connection and needs in the management of STDs.
The learning objectives for this issue are:
Recognize the limits to patient-physician confidentiality in the diagnosing and managing of patients with STDs.
Understand what constitutes appropriate documentation of sexual history, and learn how to interpret this information.
Understand the concerns of health care team members about interacting with patients with STDs and how to best approach these concerns to provide better patient care.
Learn the strengths and limitations of new strategies for diagnosing and managing STDs.
Learn about the ethical issues in HIV reporting and contact notification and the importance of knowing the laws about disclosure of HIV status in the state where you practice.