Disclosure of Sexually Transmitted Infections to Sexual Partners: A Systematic Critical Literature Review

ABSTRACT

The purpose of this review was to systematically and critically evaluate the STI disclosure literature (excluding HIV disclosure literature), summarize limitations and omissions, and identify opportunities for future research. We used the Health Disclosure Decision-Making Model (DD-MM) as a guiding theoretical framework. Following PRISMA guidelines, database searches using key terms identified 387 possible articles, 32 of which ultimately met inclusion criteria for this review. Findings indicated that individuals with STIs experience a variety of negative feelings and emotions related to the prospect of disclosure. Reasons for disclosure included moral obligation, love for partner, and desire for support, whereas reasons to not disclose included fears about partner’s reaction and response, fears of being rejected or broken up with, and beliefs about the lack of obligation. Disclosers used a variety of disclosure strategies, including priming messages, framing, and direct disclosure. Non-disclosers used strategies to pass as uninfected (i.e. passing), withdraw from relationships, and using outbreaks to time sexual activity. Among studies that examined disclosure timing, around half or fewer individuals disclosed or believed they should disclose prior to engaging in sexual activity. The findings indicated that relationship-related factors such as greater levels of commitment, relationship quality, length together, and feelings of closeness were important predictors of disclosure. Finally, some individuals experienced negative partner responses, whereas others experienced positive responses and relationship outcomes. Our review revealed that the experiences of receivers of STI disclosures are not well-represented in the literature. Implications for future research, education, and intervention are specified.

Introduction

The Centers for Disease Control and Prevention (CDC) estimated that in 2018, there were an approximately 67.6 million prevalent and 26.2 million incident sexually transmitted infections (STIs) in the United States (Kreisel et al., 2021). In other words, at any given point in time, one in five people in the U.S. had an STI in 2018, and there were over 26 million incidents reported (Kreisel et al., 2021). In the 2022 STI surveillance, the number of new chlamydia, gonorrhea, and syphilis cases reported was over 2.5 million, which has remained relatively steady since 2018 (CDC), 2024). Of all sexually active age groups, emerging adults (ages 18–29; Arnett, 2015) are most susceptible to and reported being most worried about contracting a new STI (Kirzinger et al., 2020). According to the CDC, chlamydia, gonorrhea, and syphilis have been at record highs for several years and continued to rise into 2022 (CDC, 2024). However, the CDC has indicated that data collected during the COVID-19 pandemic should be considered in light of restricted access to health care and testing during the pandemic (CDC, 2024).

Given the effect of the COVID-19 pandemic on STI rates, diagnoses, and treatment, the current review is critical. The CDC recommends a variety of methods for STI prevention, such as using prophylaxis, getting routine testing, and talking with partners about sexual histories, including disclosing an active STI to sexual partners (Centers for Disease Control and Prevention [CDC], 2022a, 2023a). A sizable body of research has been published on STI disclosure; however, much of this research does not use an explicit guiding framework, has limitations in sampling and research design, and often excludes the perspectives of disclosure recipients. As such, our objective was to conduct a systematic critical review of the literature on STI disclosure, summarize limitations and omissions within this literature, and identify essential areas for future research. The goal of a systematic review is to search, appraise, and synthesize the research on a given topic (Grant & Booth, 2009). The goal of a critical review is also to search, appraise, and synthesize research, but it also includes conceptualization of findings, including the possible generation or modification of theoretical models (Grant & Booth, 2009). Thus, we consider our review as systematic and critical.

STI cases continue to rise annually (CDC, 2024), yet the STI disclosure literature published across the last two decades has not kept pace. When individuals receive a health diagnosis, they contend with a variety of emotions and dilemmas, including whether or not they should disclose to others (Greene, 2009). Individuals diagnosed with an STI report a variety of emotions, including distress and anxiety (e.g., Kosenko et al., 2012; Melville et al., 2003; R. A. Smith et al., 2014), feelings of negative body image (Nack, 2000), and low sexual esteem (Newton & McCabe, 2008a). STI-positive individuals must also decide whether they will disclose their STI to others and to whom (hereon referred to as “receivers;” Greene, 2009). Salient receivers to consider disclosing to are sexual partners, as they face increased susceptibility for contracting the STI(s), if they did not already have the STI(s) and were not the individuals who transmitted it initially.

It is important to note here the distinction between “disclosure” and “partner notification.” Partner notification is akin to contact tracing (Ward & Bell, 2014). Partner notification involves notifying current or former partners that they were potentially exposed to an STI (CDC 2021c; Ward & Bell, 2014). There are a variety of approaches to partner notification, some of which involve the individual notifying their partner(s) directly and referring them for testing and treatment, others may involve either the provider contacting the partner directly or using an anonymous messaging service (CDC, 2021c; Ward & Bell, 2014). For example, if an individual is diagnosed with chlamydia or gonorrhea, then partner notification of some form will likely be the approach taken (CDC, 2021c).

Disclosure, sometimes referred to as “self-disclosure,” is the voluntary (or perhaps in some cases, involuntary) sharing of personal information with another person (Afifi & Steuber, 2009; Greene, 2009). It is when a person chooses to reveal information about themselves, often sensitive or secret. In the context of STIs, it is when someone reveals to another that they have or had an STI. The CDC indicates that the benefit of disclosing a positive HPV test to a partner is unclear, as it likely depends on the nature of the HPV (CDC, 2021a). It is recommended that practitioners frame HPV neutrally and counsel their patients using a list of key messages (CDC, 2021b, 2021c). The decision to notify current partners or disclose to future partners will likely depend on a variety of factors, including if the HPV is subclinical, macroscopic (e.g., genital warts), or pathologic (i.e., precancerous; CDC, 2021b, 2021c). Regarding herpes, clinical guidance encourages that providers emphasize the importance of informing current partners and any future partners before sexual activity, as herpes is a chronic and highly contagious condition, although guidance on disclosure regarding asymptomatic individuals was not provided by the CDC (CDC, 2022b). Clinical guidelines also recommend that practitioners counsel patients on the variety of methods that can be used to manage herpes and reduce the likelihood of transmission (CDC, 2022b). Disclosure could certainly be used to facilitate partner notification, but the focus of this review is on the self-disclosure of STI history to partners, not partner notification.

The Need for Guiding Frameworks

The STI disclosure literature reveals several overlapping themes, but few studies identified and utilized an explicit framework to guide their research. Using a framework to guide research on STI disclosures is necessary because they provide structure to conduct replicable research and synthesize findings for education, intervention, and policy (e.g., Coffelt et al., 2021; R. A. Smith et al., 2014). As such, we attended to studies’ use of theories and frameworks and make suggestions for the application of theory for future research. We used the Health Disclosure Decision-Making Model (DD-MM; Greene, 2009) to guide our evaluation and synthesis of the STI disclosure literature.

The Health Disclosure Decision-Making Model

Regarding the study of communication and disclosure, a variety of theoretical frameworks have been developed to explain the concealing and revealing of information. Common theories include the Communication Privacy Management Theory (CPM; Petronio, 2002), the Cycle of Concealment Model (CCM; Afifi & Steuber, 2010), the Revelation Risk Model (RRM; Afifi & Steuber, 2009), the Disclosure Processes Model (DPM; Chaudoir & Fisher, 2010), and the Health Disclosure Decision-Making Model (DD-MM; Greene, 2009). Although each of these frameworks touch upon important aspects associated with disclosure decision-making, the DD-MM is a comprehensive framework that focuses specifically on health-related disclosures (Greene, 2009; Magsamen-Conrad, 2014), which is particularly relevant for studying STI disclosure and synthesizing literature. The DD-MM indicates that individuals assess (a) information associated with the diagnosis, (b) the intended receiver of the disclosure, and (c) their disclosure efficacy. If they choose to disclose, they then consider and enact strategies for disclosure.

Assessing Information

The DD-MM suggests that when individuals are evaluating the decision to disclose or not, they consider information that is associated with the health disclosure in question. The information that individuals often consider when deciding whether or not to disclose includes any (a) stigma and (b) symptoms associated with the health condition.

Stigma

A stigma forms when an attribute, condition, or situation is inconsistent with social norms and values (Goffman, 1963). Historically, individuals with STIs have often been stigmatized (Lee & Craft, 2002; Scheinfeld, 2023), and those with STIs are often considered promiscuous, dirty, and immoral by un-infected individuals (Lo et al., 2009; Nack, 2000). The perception of stigma contributes to individuals’ decisions about disclosure (Greene, 2009), and also influences others’ beliefs about those with STIs (Lo et al., 2009; Nack, 2000). After individuals are diagnosed with an STI, many become acutely aware of the stigma associated with their condition (Lee & Craft, 2002; Newton & McCabe, 2005). STI stigma can be damaging to the sexual self (Lee & Craft, 2002; Nack, 2000; Newton & McCabe, 2008b; Swanson & Chenitz, 1993). Sometimes, the perception of this stigma inhibits disclosure to sexual partners (Lee & Craft, 2002; Nack, 2000). Many, including those in emerging adulthood, perpetuate stigmatizing messages about STIs as a way to distance themselves from susceptibility to contracting an STI and those they perceive as immoral (Hirschler et al., 2015; Nack, 2000).

Symptoms

The symptoms of the health diagnosis in question affect individuals’ decisions to disclose. If the condition does not have present, visible, or severe symptoms, an individual may decide that they do not need to disclose (Greene, 2009). For example, the visibility of a genital herpes outbreak can motivate individuals to disclose to a partner, while the absence of an outbreak may motivate individuals to withhold disclosure (Green et al., 2003; Myers et al., 2016). Research suggests that viral STIs, such as herpes, may be more stigmatizing than bacterial or parasitic STIs, given their incurable nature (Lee & Craft, 2002; Swanson & Chenitz, 1993).

Assessing the Receiver: Anticipated Reactions

When deciding whether to disclose, individuals often consider the anticipated receiver responses and anticipated outcomes of disclosure (Magsamen-Conrad, 2014). The DD-MM (Greene, 2009) uniquely considers both concepts and labels this construct anticipated reactions (Magsamen-Conrad, 2014). Anticipated reactions (responses and outcomes) are uniquely influential to the disclosure decision-making process (e.g., Green et al., 2003; Lee & Craft, 2002; Myers et al., 2016). Despite including both in the model, Magsamen-Conrad (2014) highlighted the need for the distinction of these concepts, as the differences between them are subtle but important.

Anticipated Response

When an individual discloses sensitive information, the receiver may respond in a number of ways. A response is considered the immediate verbal or nonverbal communication that occurs in direct reply to the disclosure (Magsamen-Conrad, 2014). Anticipated responses are what potential disclosers believe their intended receiver might say or do immediately following the disclosure (Magsamen-Conrad, 2014). For example, individuals reported anticipating their partner to become angry, upset, and even reject them after they disclose (e.g., Decker et al., 2011; Melville et al., 2003).

Anticipated Outcome

Anticipated outcomes are the expected immediate and long-term effects of disclosure on the discloser, the receiver, and the relationship (Greene, 2009; Magsamen-Conrad, 2014). Some people with STIs discussed fear that their partners will form judgments about their character (e.g., deciding the discloser is promiscuous or a cheater; Decker et al., 2011; Nack, 2000). Others described fear that their partner will terminate the relationship (e.g., Coffelt et al., 2021; Keller et al., 2000; Melville et al., 2003). Not all anticipated outcomes are negative; some people with STIs disclose because they anticipate a positive effect on their overall self-concept (Lee & Craft, 2002).

Assessing the Receiver: Relationship Quality

According to the DD-MM (Greene, 2009), potential disclosers also consider the quality of their relationship with the intended receiver. If the relationship is perceived as being of higher quality, then a disclosure is more likely to occur (Greene, 2009; Niccolai et al., 2008). Other relationship-related constructs are also influential to the decision to disclose, including relationship type (i.e., a committed or non-committed relationship; Arima et al., 2012; Bickford et al., 2007; Mohammed et al., 2010; Myers et al., 2016), relationship length (Arima et al., 2012; Scrivener et al., 2008), relationship closeness (Scrivener et al., 2008), and transitions in committed relationship milestones, such as moving from a dating to a cohabiting relationship (Myers, 2020).

Assessing Disclosure Efficacy

Part of the decision to disclose health-related information is the individual’s confidence in their ability to do so (Greene, 2009). If an individual feels confident in their ability to disclose their diagnosis, share information about the STI, and handle possible responses and questions, they are more likely to disclose than one who is not confident (Greene, 2009). Individuals with STIs may not know what to say or how to approach the conversation, which can motivate non-disclosure (Arima et al., 2012; Kosenko et al., 2012).

Population and Sampling Considerations

Studies on STI disclosure are also limited by a number of sample issues. For example, many studies report broad age ranges (e.g., Green et al., 2003; Myers, 2020), whereas others report no sample demographic information (e.g., Bickford et al., 2007; Emmers-Sommer et al., 2010). Being able to disaggregate the STI disclosure literature by developmental stage is important. Understanding disclosure processes among emerging adults is a critical step in addressing the increasing rates of STI diagnosis for those in this developmental period. Although the likelihood of contracting an STI is based on multiple factors, emerging adults tend to engage in more sexual behaviors that increase their susceptibility to contracting an STI, such as inconsistent condom use and sex with multiple partners (Arnett, 2015; Turchik & Garske, 2009). Younger adults (M = 31.44, SD = 11.70) are less likely to disclose an STI to a sexual partner than middle-aged adults (M = 40.93, SD = 13.32; Myers et al., 2016). Thus, we initially included sample age as an inclusion criterion for this review; specifically, to be included studies had to report that some or all participants were between 18–29, and that we were able to disaggregate findings based on participant age. Unfortunately, while conducting our review, the majority of studies we found did not allow us to disaggregate by age. As a result, we removed sample age as an inclusion criterion, but still applied an emerging adult developmental perspective when critically reviewing articles.

Prior Comprehensive Reviews

To our knowledge, two review papers have been published that focused on STI disclosure research (see Montgomery et al., 2008; Newton & McCabe, 2005). The publication dates reviewed were between 1985 and 2004 (Newton & McCabe, 2005) and 1992 and 2007 (Montgomery et al., 2008). Newton and McCabe (2005), did not specify the number of articles found and included in their review, and Montgomery et al. (2008) included 17 articles. Both did not provide a guiding structure for their reviews, limited their focus on one or two STI types (i.e., herpes and HIV), and did not include a critique of study methodologies. Since the publication of these reviews, guidelines for conducting systematic, critical literature reviews have been published, as has additional STI disclosure research. As such, this paper provides a comprehensive review of the literature on the disclosure of STIs to partners using a structured and critical framework (the DD-MM).

Study Aims

Health disclosure decisions necessitate that individuals weigh the challenges and benefits of disclosure for self, others, and relationships (Derlega et al.,1998, 2000; Greene, 2009). Studies on STI disclosure have found that those diagnosed with STIs are motivated to disclose (or not disclose) their STI to partners for a variety of reasons. Given the important role of disclosure in reducing the spread of STIs (CDC, 2022a) and the need for a critical review of this body of research, the purpose of this paper was to systematically and critically review the extant STI disclosure literature. We had the following four aims:

1. To synthesize and critically evaluate the existing research on STI disclosure within the context of the DD-MM

2. To summarize limitations and omissions in this research

3. To identify essential areas for future research with methodological recommendations

4. To identify findings that will inform sexual health education, practice, and policy

In the process of conducting this review, the opportunity to address a fifth aim appeared, which we incorporated into our review and couch most of our discussion within:

• (5) Propose additions and expansions to the DD-MM that comprehensively address the STI disclosure process

Method

We modeled our systematic critical literature review (SCLR) methods after Kågesten et al. (2016) and used PRISMA (Liberati et al., 2009) and ENTREQ (Tong et al., 2012) statements as guides (see Figure 1). We conducted a clear, replicable strategy, which is outlined below.

Figure 1. PRISMA article screening flow chart.

Step 1: Search Strategy

We used a systematic approach to identify studies using original data on STI disclosure. This review includes peer-reviewed articles from the PsycINFO, PubMed, and Web of Science databases, with no publication date restriction (i.e., from earliest recorded article to October 1 and 6, 2020, the respective dates of our initial searches; we conducted follow-up searches to capture any additional studies published since our earlier searches). EndNote was used to manage articles throughout the search process. The first author identified relevant search terms by conducting a cursory review of several STI disclosure articles and divided them into the categories “STIs” and “disclosure” (see Supplementary Tables 1, 2, and 3 for the search strategies). After finalizing search terms, controlled vocabulary terms in PsycINFO and Medical Subject Headings (MeSH) terms were identified (Supplementary Tables 1 and 2). For the PsycINFO search, we used (a) the controlled vocabulary, (b) the key terms, and (c) the controlled and key terms combined, limiting the search to “anywhere but full-text” (NOFT), articles written in English, and articles that were peer-reviewed. The combined search generated n = 605 article results. Many of these results were subsequently excluded from this review (e.g., met exclusion criteria; different research topic). For the final PsycINFO search step, exclusion terms (NOT) were added to remove irrelevant articles (Supplementary Table 1), yielding n = 207 articles. Based on results from the PsycINFO search, a search strategy for PubMed (Supplementary Table 2) was then created, which yielded n = 53 articles. Based on the results from both the PsycINFO and PubMed searches, a search strategy for Web of Science was then created, which yielded n = 116 articles (Supplementary Table 3).

The first author cross-referenced the results from the database searches with the two previous review articles on STI disclosure (Montgomery et al., 2008; Newton & McCabe, 2005). The titles and abstracts of studies included in these reviews and their reference lists were scrutinized to determine relevance to this current review. From the Montgomery et al. (2008) review, nine articles were relevant for title/abstract review, three of which were already included from the database searches. From the Newton and McCabe (2005) review, seven articles were relevant for this review. One article was already included from the database searches and was one of two duplicates from the Montgomery et al. (2008) review. Eleven articles were included from these other sources, and n = 376 from database searches, for a total of n = 387 articles to be screened.

Step 2: Abstract Screening

In step two, the first author used an abstract screening template adapted from Kågesten et al. (2016). To be included for full-text screening, studies had to: (a) introduce primary data (i.e., empirical studies), (b) include participants ages 18–29, congruent with our focus on emerging adulthood, and (c) not exclusively examine HIV/AIDS (i.e., if the focus of the study was on the disclosure of HIV/AIDS only, it was excluded; see Supplementary Table 4 for the abstract screening template used). The first author also noted whether it could be determined, from the abstract, that studies examined self-disclosure of an STI and factors associated with disclosure and/or disclosure decision-making. These two questions were not used to officially filter studies, as many abstracts did not include enough detail to address these questions. If it was unable to determined that the focus of the study included STI disclosure from the abstract, but it met the other criteria, it was included for full-text review. Of the n = 387 abstracts screened, 337 were excluded (87.1%), leaving a total of n = 50 full-texts to then be screened.

Step 3: Full-Text Screening, Data Extraction, and Critical Appraisal

Next, the first author conducted the full-text screening, data extraction, and critical appraisal simultaneously. A modified version of the standardized template developed by Kågesten et al. (2016) was used to screen the full-text articles, extract the data, and conduct the critical appraisal. The template has three separate forms for quantitative, qualitative, and mixed-methods studies. The first template section contains a series of full-text screening questions and initial quality check to determine whether the study should be included or excluded. After completing this section, we noted studies that should be excluded and stopped completing the template. Based on screening requirements, a total of n = 18 studies (36%) were excluded because they either did not focus on the self-disclosure of an STI or focused exclusively on HIV disclosure. For the remaining studies, the second section of the template was used. This contains data extraction and appraisal questions. At the end of the template is a dedicated section for calculating a global quality score. The same quality appraisal protocols as used by Kågesten et al. (2016) were used for this part of the screening.

The ENTREQ guide for synthesizing qualitative data recommends appraising the quality of articles using one of a variety of appraisal tools (Tong et al., 2012). The first author used Kågesten al.’s (2016) modified versions of the Quality Assessment Tool for Quantitative Studies (QATQS) developed by the Effective Public Health Practice Project (EPPHP, 2021) to appraise the quantitative studies, the Critical Appraisal Skill Programme(CASP, 2018) to appraise the qualitative studies, and Kågesten al.’s (2016) protocol for appraising the quality of mixed-method studies, a hybrid protocol of the QATQS and CASP. The CASP is recommended for the quality assessment of qualitative studies by the National Institutes of Health (n.d.). The QATAS was developed to address a variety of health-related research topics, has demonstrated good inter-rater agreement and can be used to evaluate a variety of quantitative studies, including observational, cross-sectional, and longitudinal studies (Armijo-Olivo et al., 2012). Low-quality articles were included in our analyses because of the 387 articles screened, just 32 were retained (8.3%). Although some studies received a low-quality rating, it is important to analyze all qualified studies to identify existing limitations and recommendations for future research. It is also important to note that in Kågesten al.’s (2016) templates, if an article omitted information needed to rate its quality in a particular area (e.g., no sampling method was stated), it was assigned a lower quality score in that particular area.

Step 4: Article Analysis

A mixed-methods synthesis approach was used to analyze the included studies. The first author created a summary table for all included studies, with information on setting, objectives, design, theory, sampling, data collection and analysis, main findings, and study quality (see Supplementary Table 5). Descriptive statistics of the studies were first analyzed as a whole, including the number of studies that explicitly used a theoretical or methodological framework, reported mean age, disaggregated by race and gender, identified a type(s) of STI(s), study design, and total sample size.

Next, rather than analyze studies with various methodologies separately, the first author synthesized the data across studies consistent with the results from each study. This synthesis can be found in Supplementary Table 5. The first author used the DD-MM (Greene, 2009) as a template to organize findings across studies. For quantitative studies, this meant examining the measures used for relevant variables and attending to how authors discussed their results relevant to the variables they tested. For qualitative studies, this meant focusing on themes authors reported while also attending to example quotes provided in the results section as well as how these were discussed in discussion sections. For mixed-methods studies, a combination approach was used for quantitative and qualitative results. The examples provided in Supplementary Table 5 are primarily qualitative, but are illustrative of both qualitative and quantitative results organized in this synthesis of data. Next, the first author reviewed detailed notes and began to organize the findings into emergent categories hierarchically. First, the overarching STI disclosure construct was specified. Next, the sub-themes of that construct were noted. Third, each sub-theme was explained. Through this process it became evident that most findings had strong overlap with the DD-MM. The first author developed a thematic codebook (Supplementary Table 6), and themes were used as codes to determine the number of studies that had findings in each theme. The second author then reviewed the thematic codebook, and both coders independently coded each article included in the review. Both coders then met to compare coding for each article.

At the conclusion of the development of the thematic codebook (Supplementary Table 6), 59 possible codes were identified. When coding articles, each coder noted all codes that applied to an article. To calculate inter-coder agreement, we noted the total number of codes each coder assigned to a particular article. If both coders coded the article identically, then the agreement for that particular article was 100%. If there were discrepancies in coding (e.g., coder 1 marked 12 codes and coder 2 marked 11 of the 12 that coder 1 marked), coders discussed until agreement was 100%. For each article, we noted the initial agreement (e.g., 11 out of 12, or 91.67%) and calculated the average across all articles. Initial inter-coder agreement was 85.4%. Discrepancies in coding were discussed until final coding agreement was 100%. Finally, findings were mapped onto the DD-MM, making suggestions for expansions (see Figure 2).

Figure 2. Expanded health disclosure decision-making model (Greene, 2009; McMahan & Olmstead)

Results

Study Characteristics

Of the 32 studies that met the inclusion criteria for this review (see Supplementary Table 5 for all study characteristics and associated citations), 11 were quantitative (34.4%), 15 were qualitative (46.9%), and six were mixed-methods (18.7%). Of the 11 quantitative studies, eight were cross-sectional, one was longitudinal, one was a randomized controlled trial, and one was a cross-sectional quasi-experimental design. Of the 15 qualitative studies, five used Grounded Theory, one used Interpretive Phenomenological Analysis, and nine did not specify the qualitative methodology used. All mixed-methods studies were cross-sectional and did not specify the methodology used for the qualitative portion of the study.

After beginning the data extraction process, we removed the requirement that studies have findings for emerging adults disaggregated. Most studies had broad age ranges and/or did not include information that would enable disaggregation. Of the 32 studies included, 20 reported a mean age. Ten studies explicitly mentioned and used a theoretical framework: one quantitative study, two mixed-methods studies, and seven qualitative studies (two of these did not mention a theory but used a Grounded Theory methodology; two studies explicitly used a theory; three studies used both an explicit theory and Grounded Theory). Nineteen of the studies used predominantly White samples, and an additional eight studies did not report the race/ethnicity of participants. Five studies included men only, 10 included women only, and 17 included men and women (Mohammed et al., 2010 analyzed men and women separately). Most (19) studies were conducted in the United States, followed by seven in the United Kingdom and two in Australia. Four studies did not specify where the research was conducted. Most studies used either convenience sampling (18), purposive sampling (8), or a combination of the two (1). One study used snowball sampling, one a combination of convenience and snowball sampling, one through referral from a clinical practice, and two referred readers to other publications for the details of the sampling method.

A variety of STIs were included in the studies. Herpes (n = 9) and HPV (n = 10) were most common. Three studies examined herpes and HPV. Three examined chlamydia only, and three examined chlamydia and gonorrhea, one of which also included the parasitic STI trichomoniasis (Mohammed et al., 2010). The remaining four studies either did not specify the STIs included or described including bacterial, viral, and parasitic STIs. Thus, 22 studies examined viral STIs, six examined bacterial, and four were unspecific.

The mean sample size for quantitative studies was M_N = 430 (range = 54–1282), M_N = 43.5 (range = 5–151) for qualitative studies, and M_N = 148 (range = 50–291) for mixed-methods studies. Studies were published between 1993 and 2022. Quantitative studies were published between 2008 and 2021 (two published before 2010, nine published in or after 2010). Qualitative studies were published between 1993 and 2022 (nine published before 2010, six published in or after 2010). Mixed-methods studies were published between 2000 and 2021 (four published before 2010, one published in 2010, and one published in 2021). In total, we rated three studies as strong quality, 20 as moderate, and nine as low quality. We rated one quantitative and two qualitative studies as strong; seven quantitative, 10 qualitative, and three mixed-methods studies as moderate; and three quantitative, two qualitative, and three mixed-methods as low.

Thematic Synthesis

The themes found aligned with and expanded on the DD-MM (Greene, 2009). Findings illustrate the utility of the DD-MM for conducting research on STI disclosures but also highlight the DD-MM’s limitations as applied to STIs. The full thematic summary can be found in Supplementary Table 6. Below we provide an overview of findings. Our conclusions are not necessarily generalizable but are situated within the context of the studies reviewed. We note here that although the majority of studies examined actual disclosers/nondisclosers, some examined the perceptions of those who had not contracted an STI.

Feelings and Emotions about Disclosure

Participants reported a variety of feelings and emotions regarding their diagnosis and the prospect of disclosure. Some experienced anger with/blamed the partner they believed infected them (Bennett et al., 2022; Cunningham et al., 2007; Kosenko et al., 2012; Melville et al., 2003; Niccolai et al., 2008; Perrin et al., 2006; Swanson & Chenitz, 1993). Many reported worry and anxiety associated with their STI, particularly the process of disclosure (Bennett et al., 2022; Bickford et al., 2007; Duncan et al., 2001; Kosenko et al., 2012; McCaffery et al., 2006; Melville et al., 2003; Nack, 2000; Newton & McCabe, 2008b; Perrin et al., 2006; Shepherd, 2010; R. A. Smith et al., 2014). Some reported guilt or self-blame for possibly exposing their partner (Bennett et al., 2022; Duncan et al., 2001; Feinstein et al., 2018; McCaffery et al., 2006; Melville et al., 2003; Perrin et al., 2006; Temple-Smith et al., 2010).

The prominent emotion reported across studies was fear. By-and-large, participants were fearful of their partner’s reaction (i.e., emotional reactions such as anger; Arima et al., 2012; Bennett et al., 2022; Decker et al., 2011; Duncan et al., 2001; Green et al., 2003; Lee & Craft, 2002; Myers et al., 2016; Nack, 2000; Temple-Smith et al., 2010), of how their partner would perceive them (i.e., being viewed negatively or as promiscuous; Bennett et al., 2022; Green et al., 2003; Melville et al., 2003; Nack, 2000; Perrin et al., 2006; Scrivener et al., 2008), being broken up with (Arima et al., 2012; Bennett et al., 2022; Coffelt et al., 2021; Keller et al., 2000; Melville et al., 2003; Shepherd, 2010), and being rejected by their partner. Fear of rejection could either be fear that a committed partner would reject them, or that a casual partner would reject sex with them, if they disclosed (Arima et al., 2012; Bickford et al., 2007; Cunningham et al., 2007; Decker et al., 2011; Green et al., 2003; Kosenko et al., 2012; Melville et al., 2003; Nack, 2000; Newton & McCabe, 2008b; Niccolai et al., 2008; Scrivener et al., 2008; Shepherd, 2010; Swanson & Chenitz, 1993; Temple-Smith et al., 2010).

Reasons for Disclosure

Despite reporting a number of negative emotions and feelings, many individuals chose to disclose and reported various reasons for disclosure. Some believed that being honest about the STI was the best policy, especially in the context of committed relationships; honesty and transparency were important aspects of commitment identified by participants (Arima et al., 2012; Keller et al., 2000; Myers, 2020; Scrivener et al., 2008). Many believed that they had a moral obligation to disclose. Disclosing the STI is morally correct and the “right thing to do” (Arima et al., 2012; Bennett et al., 2022; Cunningham et al., 2007; Green et al., 2003; Keller et al., 2000; Kosenko et al., 2012; Lee & Craft, 2002; Myers et al., 2016; Newton & McCabe, 2008b; Scrivener et al., 2008; R. A. Smith et al., 2014; Swanson & Chenitz, 1993; Temple-Smith et al., 2010). Some emphasized that it is not just a moral choice but an obligation to disclose, to prevent the spread of infection, and because the partner has a right to know, so that they can care for their own health and make informed decisions about engaging in sexual behaviors (Arima et al., 2012; Cunningham et al., 2007; Keller et al., 2000; Kosenko et al., 2012; Lee & Craft, 2002; Myers, 2020; Newton & McCabe, 2008b; Scrivener et al., 2008; R. A. Smith et al., 2014; Swanson & Chenitz, 1993; Temple-Smith et al., 2010).

In a similar vein, some participants were motivated to disclose out of concern for the partner’s health/to protect their partner (Bennett et al., 2022; Cunningham et al., 2007; Keller et al., 2000; Nack, 2000; Scrivener et al., 2008; Swanson & Chenitz, 1993; Temple-Smith et al., 2010). This could be a general health concern or associated with specific STI consequences. For example, some participants diagnosed with chlamydia often discussed how undiagnosed/untreated chlamydia can lead to infertility, and they wanted to protect their partner from this experience (Temple-Smith et al., 2010). Beyond caring about their partner’s health, some disclosed out of general caring for their partner. More specifically, they “cared about” and/or “loved” their partner, so they were motivated to disclose (Arima et al., 2012; Green et al., 2003; Keller et al., 2000; Myers et al., 2016).

Some disclosure motivations were rooted in the self-assessment/confirmation process (Lee & Craft, 2002; Nack, 2000; Perrin et al., 2006). For some, disclosure was therapeutic and helped them address and combat the STI stigma they experienced (Lee & Craft, 2002; Nack, 2000; Perrin et al., 2006). Some disclosed to solicit support and identity-confirming messages from their partner (Lee & Craft, 2002; Myers et al., 2016; Nack, 2000; Perrin et al., 2006; R. A. Smith et al., 2014; Swanson & Chenitz, 1993). Some also disclosed to maintain their involvement in romantic and sexual relationships (Lee & Craft, 2002). Although disclosure brought the potential for rejection, some believed that non-disclosure meant avoiding sex and relationships altogether, and they were willing to make this sacrifice (Lee & Craft, 2002). In other words, they risked rejection rather than avoid relationships altogether.

Other reasons for disclosure were more circumstantial or forced. Some participants used their diagnosis as a way to confront their partner because they believed they transmitted the STI. In these instances, disclosing an STI also meant confronting one’s partner about the possibility of infidelity or knowingly exposing them (Arima et al., 2012; Bennett et al., 2022; Keller et al., 2000; Myers et al., 2016; Scrivener et al., 2008; Temple-Smith et al., 2010). For others, disclosure was not necessarily voluntary but forced by the emergent need to explain the use of prophylaxis (condoms or medication) or the presence of STI symptoms/outbreaks (Arima et al., 2012; Green et al., 2003; Keller et al., 2000; Lee & Craft, 2002; Myers et al., 2016; Scrivener et al., 2008; Swanson & Chenitz, 1993).

Reasons Against Disclosure

Fear or anticipation of emotional reactions, behavioral responses, and rejection were arguably the most salient reasons for non-disclosure. Anticipating or fearing negative emotional reactions (Arima et al., 2012; Decker et al., 2011; Duncan et al., 2001; Green et al., 2003; Lee & Craft, 2002; Myers et al., 2016; Nack, 2000; Temple-Smith et al., 2010) or responses (Arima et al., 2012; Bennett et al., 2022; Cunningham et al., 2007; Decker et al., 2011; Green et al., 2003; Kosenko et al., 2012; Nack, 2000; Niccolai et al., 2008; Scrivener et al., 2008; Temple-Smith et al., 2010) were abundant. Many anticipated responses motivated non-disclosure, such as being accused of cheating, the partner sharing the information with unintended others, or even experiencing violent retaliations. Similarly, fear of rejection (Arima et al., 2012; Bickford et al., 2007; Coffelt et al., 2021; Cunningham et al., 2007; Emmers-Sommer et al., 2010; Lee & Craft, 2002; McCaffery et al., 2006; Myers et al., 2016; Newton & McCabe, 2008b; Shepherd, 2010; Swanson & Chenitz, 1993) and relationship termination (Arima et al., 2012; Coffelt et al., 2021; Keller et al., 2000; Lee & Craft, 2002; Myers et al., 2016) were also common. Rather than face the possibility of being rejected or abandoned, these participants chose to keep the information to themselves.

Another salient reason for non-disclosure was the belief that there was no obligation to tell. Participants who chose not to disclose believed that they were not obligated to inform the partner, for various reasons. This was most often the case with non-committed, casual sex relationships. These participants believed that the nature of the relationship did not necessitate disclosure (Arima et al., 2012; Coffelt et al., 2021; Emmers-Sommer et al., 2010; Green et al., 2003; Keller et al., 2000; Lee & Craft, 2002; Myers et al., 2016; Newton & McCabe, 2008b; Niccolai et al., 2008; Perrin et al., 2006; Scrivener et al., 2008; Swanson & Chenitz, 1993). For example, one respondent said, “If I would have a one-night-stand type of situation, I wouldn’t tell … ” (Swanson & Chenitz, 1993, p. 290). Similarly, some reported an entitlement to privacy as a motivation to withhold disclosure (Coffelt et al., 2021; Emmers-Sommer et al., 2010; Keller et al., 2000; Niccolai et al., 2008; Perrin et al., 2006; Shepherd, 2010).

Additional reasons for non-disclosure that were identified included that some participants thought that it was less necessary to disclose because they believed they had taken appropriate steps to reduce STI transmission (Bennett et al., 2022; Emmers-Sommer et al., 2010; Green et al., 2003; Keller et al., 2000; McCaffery et al., 2006; Myers et al., 2016; Scrivener et al., 2008). For example, some reported that if they did not have a visible herpes outbreak and were on antiviral suppressive therapy, that the transmission of herpes had been reduced and managed and, as a result, opted to not disclose (Green et al., 2003). One respondent said, “The way I see it is that if I am in control of the herpes and I can control it with my tablets [antiviral suppressive medication] … then I don’t feel I have to tell” (Green et al., 2003, p. 43). Some participants believed that if they were using condoms, that disclosure was not required (Arima et al., 2012; Green et al., 2003; Keller et al., 2000; Myers et al., 2016; Newton & McCabe, 2008b; Niccolai et al., 2008; Scrivener et al., 2008). Finally, in the context of HPV disclosures, some individuals reported not disclosing based on advice received from their health practitioners (Keller et al., 2000; McCaffery et al., 2006; Nack, 2000). Specifically, if there are no recurrences of HPV, or after a series of normal pap smears, HPV is often considered to be inactive (Jewell, 2020). Based on this inactivity and clinical guidelines (CDC, 2021b), providers counseled participants that there was no need to tell future partners about the HPV (Bennett et al., 2022; Keller et al., 2000; McCaffery et al., 2006; Nack, 2000).

Other reasons for non-disclosure included feeling shame (Coffelt et al., 2021; Emmers-Sommer et al., 2010; Myers et al., 2016; Perrin et al., 2006) or embarrassment (Arima et al., 2012; Coffelt et al., 2021; Emmers-Sommer et al., 2010; Keller et al., 2000; Scrivener et al., 2008; Shepherd, 2010). Some participants reported non-disclosing due to logistical barriers like not knowing the partner’s contact information (Arima et al., 2012; Decker et al., 2011; Feinstein et al., 2018; Niccolai et al., 2008; Temple-Smith et al., 2010). Some reported a lack of efficacy, not knowing how to approach the situation (Arima et al., 2012; Kosenko et al., 2012; McCaffery et al., 2006; Scrivener et al., 2008). Others reported that they did not disclose because they were either unaware that they had an STI at the time (Arima et al., 2012; Coffelt et al., 2021; Decker et al., 2011; Emmers-Sommer et al., 2010), were in denial (Feinstein et al., 2018; Nack, 2000), or had not had sex with their partner yet (Arima et al., 2012; Emmers-Sommer et al., 2010; Keller et al., 2000; Myers et al., 2016). Finally, some were motivated to withhold disclosure because they felt angry and betrayed or they were withholding in retaliation against the partner they believed transmitted the infection to them (Arima et al., 2012; Coffelt et al., 2021; Cunningham et al., 2007; Feinstein et al., 2018; Niccolai et al., 2008; Temple-Smith et al., 2010).

Disclosure and Non-Disclosure Strategies

A few studies described the use of strategies for disclosure and non-disclosure. Some participants used “priming messages” to assess their partner’s potential reaction, not disclosing their STI initially, but initiating conversations about STIs. These could include broaching the subject of STIs generally, or telling jokes about STIs and seeing how the partner reacts (Coffelt et al., 2021; Green et al., 2003; Swanson & Chenitz, 1993). Some also used message framing to decrease the likelihood of a negative reaction (Bennett et al., 2022; Coffelt et al., 2021; Green et al., 2003; McCaffery et al., 2006; Perrin et al., 2006; Yang & Pittman, 2017). These participants downplayed the severity of symptoms or framed the STI in a different way (e.g., emphasizing HPV as a cancer-related issue and not sexually transmitted), hoping to decrease the possibility of negative responses. One study examined how framing of HPV as an STI versus a cancer-causing infection possibly increased disclosure intentions, but they did not find an effect of framing (Yang & Pittman, 2017). Two studies found that participants used partners’ disclosures or symptoms (e.g., a cold sore) to reciprocate disclosure (Lee & Craft, 2002; Swanson & Chenitz, 1993).

A few studies described participants using direct disclosure strategies, where participants were clear and direct about their STI status with their partners (Bennett et al., 2022; Coffelt et al., 2021; Green et al., 2003; Newton & McCabe, 2008b; Swanson & Chenitz, 1993). Finally, two studies also discussed the delivery method used to disclose. Disclosers may use different methods to communicate, such as face-to-face disclosure, phone calls, or text messages (Bennett et al., 2022; Coffelt et al., 2021).

Regarding non-disclosure strategies, some participants described “passing” as uninfected to avoid disclosing (Lee & Craft, 2002). Because most STIs are not typically visible in daily interactions, these participants were able to avoid disclosure because their STI was not able to be seen by others (Lee & Craft, 2002). Some described slowing down the sexual progression of relationships to avoid disclosure or withdrawing from/ending relationships altogether. Rather than face the potential for rejection, some decided to forgo pursuing sexual and romantic relationships (Bennett et al., 2022; Lee & Craft, 2002; Melville et al., 2003; Myers et al., 2016; Nack, 2000; Newton & McCabe, 2008b; Shepherd, 2010; Swanson & Chenitz, 1993). Finally, some described using the presence or absence of outbreaks (i.e., herpes outbreaks) to time their sexual interactions. These participants would abstain from sex when experiencing an outbreak and engage in sex when no symptoms were present, due to their belief that a lack of symptoms indicated the herpes could not be transmissible (Green et al., 2003; Swanson & Chenitz, 1993).

Disclosure Timing

Several studies investigated the timing of STI disclosures (Arima et al., 2012; Bickford et al., 2007; Emmers-Sommer et al., 2010; Keller et al., 2000; Kosenko et al., 2012; Lee & Craft, 2002; Myers, 2020; Shepherd, 2010; Swanson & Chenitz, 1993). Research suggests that people generally believe that disclosure should always occur prior to sexual activity (Emmers-Sommer et al., 2010). Across studies, around half of participants disclosed prior to sexual debut. Myers (2020) found that 59% of participants disclosed prior to receiving oral sex, and 46% prior to giving oral sex. Further, just over half disclosed before vaginal (59%) and anal (56%) intercourse. Bickford et al. (2007) found that 44% of participants reported always disclosing before, but 56% disclosed sometimes before (25%) or always after (31%) sex. Some individuals described uncertainty about the best time to disclose (Kosenko et al., 2012). For example, one woman with HPV said, “It was just, ‘When do I tell him?’ Because I don’t want it to be like I was trying to deceive him or something, and I didn’t want to say it too late or early. So, it was very much like, ‘What’s the best timing?’” (Kosenko et al., 2012, p. 540).

Relationship Factors

The characteristics of relationships (i.e., relationship type, duration, closeness, and quality) were commonly discussed across studies and contributed to the disclosure decision-making process. Disclosure was more likely to occur in committed, longer-lasting, closer, and higher-quality relationships (Arima et al., 2012; Bennett et al., 2022; Bickford et al., 2007; Coffelt et al., 2021; Cunningham et al., 2007; Duncan et al., 2001; Green et al., 2003; Keller et al., 2000; Lee & Craft, 2002; Mohammed et al., 2010; Myers et al., 2016; Newton & McCabe, 2008b; Niccolai et al., 2008; Pfeiffer et al., 2016; Scrivener et al., 2008; Swanson & Chenitz, 1993). There are several overlapping themes that can explain why these characteristics elicited disclosure, such as caring about/loving the partner, beliefs about honesty in relationships, and beliefs about the obligation to disclose to casual partners. Further, transitions in relationships were important catalysts for disclosure. Authors found that changes in commitment level or reaching relationship milestones may elicit disclosures (Bickford et al., 2007; Green et al., 2003; Marhefka et al., 2012; Myers, 2020; Myers et al., 2016; Shepherd, 2010; Swanson & Chenitz, 1993). For example, Myers (2020) found that as participants moved through relationship milestones indicative of increases in commitment (e.g., moving from engagement to marriage), they were more likely to disclose. Similarly, Green et al. (2003) found that transitions to cohabitation elicited disclosure.

Individual Factors

A number of individual-level factors were examined across studies. Sexual partner number was associated with disclosure; people with fewer sexual partners were more likely to disclose their STI to current partners (Arima et al., 2012; Mohajer et al., 2021; Mohammed et al., 2010; Niccolai et al., 2008). Age of participant was another factor associated with disclosure. Specifically, participants younger than 24 (Mohammed et al., 2010), with a mean age of 19 (Pfeiffer et al., 2016) and 31.44 (Myers et al., 2016) were less likely to disclose than participants 24 years or older, with a mean age of 20 and 40.93, respectively. Niccolai et al. (2008) found that age at first intercourse was associated with intentions not to notify their partner; participants who had their first intercourse at age 14 or younger were more likely to report intentions not to notify than participants whose first intercourse was after age 14.

Across studies, gender (Coffelt et al., 2021; Cunningham et al., 2007; Duncan et al., 2001; Mohammed et al., 2010; Pfeiffer et al., 2016; Yang & Pittman, 2017) and STI type (Coffelt et al., 2021; Cunningham et al., 2007; Newton & McCabe, 2008a; Temple-Smith et al., 2010) did not typically differentiate disclosure, but researchers often described the differences in viral STI stigma (which tends to be discussed as more pervasive) and bacterial STI stigma and the sexual double standard, which suggests that women tend to experience more stigmatization for STIs as opposed to men (e.g., G. Smith et al., 2008). Participants echoed these constructs. Highlighting the stigmatization that women with STIs experience, one young woman said, “They wouldn’t say nothing to the guy. It would all be on the girl. The girl would just be called a freak … She burning, she dirty, she a freak” (Cunningham et al., 2007, p. 47)., A young man diagnosed with chlamydia discussed the emotional difficulty of disclosing but speculated how disclosure of “more serious” STIs could elicit suicide: “ … and I can see how someone would commit suicide for that reason. They’d rather just kill themselves than tell the other partner. Not necessarily chlamydia, but with a serious or half serious one, you know” (Temple-Smith et al., 2010, p. 421).

Some researchers also identified other individual factors that may differentiate disclosure, including race (Mohajer et al., 2021; Niccolai et al., 2008), a self-reported history of STIs (Mohajer et al., 2021; Niccolai et al., 2008), and exposure to interpersonal violence (IPV; Decker et al., 2011). Niccolai et al. (2008) found that Black participants were more likely to have non-disclosure intentions than non-Black participants. Mohajer et al. (2021) found that male participants who reported as Asian, Hawaiian/Pacific Islander, or Native American or with a self-reported history of genital herpes were less likely to believe that a person with herpes should disclose than White, Black, or Hispanic/Latino participants or participants with no self-reported history. Participants with a personal history were also less likely to intend to disclose to future partners (Mohajer et al., 2021). Decker et al. (2011) found that participants who had experienced IPV were more likely to fear notifying partners.

Outcomes of Disclosure and Non-Disclosure

Several studies asked participants what the outcomes of the disclosure were. Some disclosers reported their partner reacted negatively, rejected them, broke up with them, stated the STI was not transmitted by them (which was often interpreted as a negative or rejecting response), and threatened or became violent, which is consistent with many of the fears surrounding disclosure (Arima et al., 2012; Bennett et al., 2022; Decker et al., 2011; Emmers-Sommer et al., 2010; Feinstein et al., 2018; Green et al., 2003; Nack, 2000; Newton & McCabe, 2008b; Shepherd, 2010; Temple-Smith et al., 2010). Others reported their partner reacted positively, provided emotional support, asked questions and sought knowledge; some partners were even relieved, believing the disclosure was going to be something “worse” (Arima et al., 2012; Bennett et al., 2022; Emmers-Sommer et al., 2010; Green et al., 2003; Keller et al., 2000; Lee & Craft, 2002; McCaffery et al., 2006; Nack, 2000; Newton & McCabe, 2008b; Scrivener et al., 2008; Shepherd, 2010; Swanson & Chenitz, 1993; Temple-Smith et al., 2010). Further, some disclosers reported that as a result of the disclosure, they experienced increases in commitment, communication, and closeness with their partner (Bennett et al., 2022; Coffelt et al., 2021; Melville et al., 2003; Newton & McCabe, 2008b; Scrivener et al., 2008; Temple-Smith et al., 2010). Non-disclosers had (or the authors discussed this possibility) higher levels of anxiety and depression and lower levels of sexual-esteem and satisfaction than disclosers, and expressed guilt and regret about their decision to withhold disclosure (Duncan et al., 2001; Keller et al., 2000; Newton & McCabe, 2008a, 2008b; Scrivener et al., 2008; Swanson & Chenitz, 1993).

Discussion

The purpose of this article was to systematically and critically review the extant disclosure literature, identify limitations and omissions, and provide recommendations for future research, education, and intervention. The results from this review suggest that previous studies have been primarily qualitative, moderate in quality, and without a theoretical framework. We couch our discussion of the results within the DD-MM, which we used to guide our review.

Applying the Disclosure Decision-Making Model (DD-MM)

Recommendations for DD-MM Additions

The DD-MM suggests that individuals assess a great deal of information when deciding whether to disclose a health condition. The model begins by suggesting that individual first assess information associated with the diagnosis, including its symptoms, associated stigma, and relevance to others. Our review reveals that when processing the decision to disclose, individuals are assessing concepts that precede information assessment. When diagnosed with an STI, people are confronted with their former STI beliefs (East et al., 2010). They are often challenged by their former opinions about people with STIs (e.g., dirty, promiscuous) and proceed through complex identity-healing experiences (East et al., 2010; Lee & Craft, 2002; Nack, 2000).

When confronted with the decision to disclose, personal beliefs and values emerged as common reasons for disclosure, including the beliefs that honesty is important, disclosure is morally correct, and people with STIs are obligated to disclose. These beliefs could stem from pre-diagnostic ideals, which is the first of our recommended additions (Pre-Diagnosis Beliefs). Although stigma is already in the DD-MM, stigma assessment also occurs upon diagnosis. Individuals may first assess the STI stigma upon diagnosis, but then must reassess when the opportunity to disclose is present. Diagnosis is an important turning point in this process and is the second recommended model addition (Diagnosis [Emotions and Experiences]).

The emotions and experiences that individuals have upon diagnosis directly influence experiences of the “self” (East et al., 2010; Nack, 2000). For many, the sexual self is “damaged” upon diagnosis (Nack, 2000), and these deeply meaningful, symbolic processes certainly influence disclosure decision-making. As such, our third recommended addition is Assessing the Self. Emotions, beliefs, and self are currently absent from the DD-MM but are part of the disclosure decision-making process. Thus, we recommend that these constructs be added to the beginning of the model, to better represent the complete process that individuals with STIs experience when deciding to disclose (see Figure 2).

Recommendations for DD-MM Expansions

Beyond the recommended additions discussed above, we also found constructs that may expand the DD-MM as it is applied to STI disclosures. The DD-MM describes the process of assessing the receiver as two-fold: assessing the quality of the relationship and anticipated reactions. Findings from our review suggests that quality is an important factor for disclosure, but there are other relationship constructs that are important as well. Specifically, the type of relationship the discloser has with their intended receiver is a critical factor to consider when disclosing. Several studies found that many participants believed that it was unnecessary to disclose within non-committed casual sex relationships. An individual could describe their relationship with a casual sex partner as high quality but withhold disclosure because they are not committed to that partner.

Other important relationship constructs were length, closeness, and relationship milestones. Individuals who had been with partners longer and who were closer to their partner were more likely to disclose. Changes in relationships may also elicit disclosure. For example, a couple in a committed relationship transitioning from living separately to cohabiting (a milestone; Myers, 2020) can facilitate disclosure. Green et al. (2003) found that several participants identified moving in together as the catalyst for disclosure, because it either made hiding herpes outbreaks or antiviral medication more difficult, or it was symbolic of increased commitment. As such, we recommend that the stage Assess the Receiver should be expanded to Assess Anticipated Reactions (Responses and Outcomes) and Assess the Relationship. Assessing the relationship involves considering the type, length, closeness, milestones, and quality of the relationship.

Finally, the DD-MM includes a step in the model to describe the outcomes of the disclosure but does not specify these outcomes (Greene, 2009). As both Greene (2009) and Magsamen-Conrad (2014) described, the research on outcomes for discloser, receiver, and relationship is limited. Our review revealed four outcome areas, although these findings are fewer than those of preceding parts of the model. Specifically, there are receiver responses (positive and negative), receiver outcomes (positive and negative), relationship outcomes (positive), and non-discloser outcomes (negative).

Based on these findings and Magsamen-Conrad’s (2014) discussion, we recommend that the DD-MM stage Outcomes be expanded to Responses and Outcomes and include the following components, all of which can be positive, negative, or neutral: (Non) Discloser Outcomes, Receiver Responses, Receiver Outcomes, and Relationship Outcomes. (Non) Discloser Outcomes may include emotional outcomes the individual experiences as a result of disclosing (e.g., relief) or withholding disclosure (e.g., guilt). Receiver Responses are actual responses receivers have to the disclosure, including emotional (feelings and behaviors), support, reciprocity, and avoidance. Receiver Outcomes can include emotional (e.g., negative feelings toward discloser) and informational (e.g., becoming more educated about STIs) outcomes that the receiver experiences after the disclosure. Relationship Outcomes can include positive (e.g., increased commitment) or negative (e.g., relationship dissolution) outcomes that occur as a result of the disclosure.

Implications for Research, Education and Intervention

Our review revealed methodological opportunities for future research. Of the 32 studies included, 19 used predominately White samples and eight failed to report racial demographic characteristics. Future research should be inclusive of racial/ethnic minorities’ experiences with STI disclosure, as this will inform health equity efforts (CDC, 2023b), as would a focus on disclosure experiences among sexual minority individuals. The majority of studies in our review did not report participants’ sexual orientations nor did they address how disclosure experiences differed based on sexual orientation. As such, it is critical that future research collect and report demographic information such as sexual orientation, and also report potential variations in disclosure experience among sexual minority individuals. Furthermore, the articles reviewed used a binary approach to assessing gender’s impact on disclosure. Future research would benefit from greater gender inclusivity. Increased transparency and thorough reporting of results are additional methodological opportunities. For example, 12 of the 32 articles reviewed did not report a mean age for participants, which impeded our ability to determine the effects of age and development on disclosure, as did the absence of guiding theoretical frameworks. Only 10 studies reviewed used a theory or framework to guide their research. Future research on STI disclosure should rely on guiding frameworks, such as the DD-MM and our recommended expansions, the emerging adulthood framework (Arnett, 2015), or others relevant to the particular field of study.

In addition to methodological opportunities, this review identified the areas of STI disclosure that have been addressed in research and highlights the need for future research within these areas, including assessing receiver experiences. The person with the STI is only one part of the relationship dyad (or triad). To understand the complexity of this process, future research must examine the expectations and experiences of disclosure recipients. Further, after understanding more clearly disclosers and receivers, researchers should investigate how these processes transpire among sexual partners. Each individual has their own unique experience, but these are occurring within the context of the relationship. Examining these relationship dynamics will further illuminate the disclosure process.

It is also important that future research make the distinction between “disclosure” and “partner notification” and is clear about which concept is under study. In some articles, these terms have been used synonymously, but they are typically referring to two distinct concepts. Partner notification has an established body of research and is an effective STI prevention tool (CDC, 2021c; Ward & Bell, 2014); there is still much we can learn about the STI self-disclosure process, including the experiences of receivers. By making clear distinctions between these two terms, researchers can continue to study these important concepts. Additionally, future research on disclosure timing could help further distinguish “disclosure” and “partner notification.” Partner notification typically occurs after a person is potentially exposed, whereas disclosure appears to happen before or after sexual activity and potential exposure, as our review revealed. Future research could help clarify the difference between partner notification and disclosure, especially in cases when self-disclosure occurs after potential exposure.

The findings from this review highlight individuals’ gaps in sexual health knowledge. Many believed, especially in the case of herpes, that being asymptomatic, STI dormancy, and using prophylaxis were enough to completely prevent transmission, and this negated the necessity for them to disclose. Although the likelihood of the transmission of herpes is decreased when asymptomatic and using prophylaxis, it is still possible (CDC, 2022b). A lack of sexual health knowledge indicates that many individuals are not receiving sufficient comprehensive sexual health education. This is not surprising, particularly in the United States, as comprehensive sex education remains taboo, rather than the norm (Fields et al., 2015). Rather than being taught how to correctly use prophylaxis, identify its limitations, and understand the scope and transmissibility of STIs, youth are only encouraged to be abstinent (Fields et al., 2015). These findings highlight the need for continuous comprehensive sexual health education throughout the life course and an increase in the number of states that offer comprehensive sex education. In addition, health care providers should take steps to increase available STI information and dissemination to promote individuals’ knowledge of and understanding about STIs, among youth and those in established and late adulthood.

Findings from this review suggest that some individuals with STIs are not confident in their ability to disclose and have misconceptions about the transmissibility of their infections. Participants reported a lack of efficacy, not knowing how to approach the disclosure or knowing what to say. As such, interventions aimed at improving disclosure efficacy and addressing knowledge gaps regarding STIs are warranted. Health practitioners are often the first people individuals interact with after their diagnosis. Their interactions with health providers may determine if and how they pursue disclosure in the future. If practitioners are stigmatizing, individuals may internalize that stigma and withhold disclosure. Practitioner advice about disclosure may also influence these decisions. The advice that practitioners may give patients will vary depending on the type of STI, which can also inform disclosure-efficacy coaching. This would be an opportunity to provide counseling about how to notify their current partner and deliver treatment, encourage routine testing, and discuss disclosure strategies should future instances arise. Regardless of the type of STI, patients could be referred to more in-depth counseling services, if necessary, to process the diagnosis and develop strategies for disclosure, should they decide to do so. Shepherd (2010) found that cognitive behavioral therapy improved disclosure efficacy and skills, and reduced false beliefs and cognitive distortions about disclosure.

Although the findings from this review have several implications for disclosers and disclosure-based research, future research on the experiences of both disclosers and receivers, as well as education and interventions, should take care to adopt a destigmatizing approach. By studying “disclosers” and “receivers,” research may be inherently putting the responsibility for initiating sexual health conversations solely on the person with the STI. Furthermore, the idea of taking personal responsibility for sexual health decision-making neglects to acknowledge health inequity. In the United States, STI diagnoses are higher among minority and marginalized populations, which are not caused by being any given gender, race, ethnicity, or sexual orientation inherently, but by societal issues that contribute to these disparities and impede access to sexual health knowledge and care (CDC, 2023b). Results from our review suggest that disclosure may be impeded by belonging to a racial minority group (e.g., Mohajer et al., 2021; Niccolai et al., 2008) or be more difficult for women (e.g., Cunningham et al., 2007), which may be attributed to health inequity and stigma. When providing education about sexual health and well-being, we should work to destigmatize sexual health conversations, educate about social determinants of health, and empower communities to improve their health using community engagement methods (CDC, 2023b). Each person interested in pursuing sexual activity with another, regardless of whether they have an STI, should feel empowered to facilitate conversations about their sexual health and wellness with others, including conversations about consent, contraception, preferred sexual behaviors, sexual histories and STI status.

Furthermore, although disclosure is important for reducing the spread of STIs and helping partners make informed sexual health decisions, it is important that we continue to consider the sensitive nature of STI disclosure, and that for some individuals, it may not be the safest decision to make (e.g., Decker et al., 2011). Providing individuals with accurate sexual health knowledge, ample opportunities for testing and treatment, and helping them build confidence in their sexual decision-making is paramount.

Limitations and Conclusions

There are several limitations of this review that must be considered. First, we excluded HIV disclosure from the review. HIV disclosure has been reviewed and studied extensively (Greene, 2009), and the process of HIV disclosure is thought to be different from the disclosure of other STIs due to its unique stigma (Greene, 2009; Nack, 2000). However, excluding these studies may have omitted important findings, such as describing how the disclosure of other STIs is similar to or different from HIV disclosure. Additionally, despite the systematic approach used to conduct the review, our use of the DD-MM to frame our review of articles may have introduced unintended bias. Using theories and frameworks to guide research is important, but by approaching the review of articles with a framework in mind, rather than using a narrative approach, we may have included information that would otherwise have been excluded or vice versa. Other limitations that may affect the legitimacy of our review are the parameters that we used to limit articles. Specifically, by only including papers published in English, we may have biased the results by only including Western perspectives. Another limitation is the limited number of reviewers involved in the process. The first author was responsible for all article screening and data extraction. Despite following a standardized review template, using only one screener could have limited the articles that we included in our review.

Despite these limitations, the results from this review synthesize many of the factors associated with the STI disclosure decision-making process and reveal important directions for future work. Individuals diagnosed with STIs may be in vulnerable positions and may face difficult decisions, the outcomes of which can be harmful to their identity and relationships. The process of disclosure is complex. Certain contexts, particularly committed relationships, elicit disclosure, whereas others inhibit disclosure. Disclosure is an interpersonal process (Greene, 2009) that involves not just the individual faced with the decision to disclose, but the intended receiver. One of the key factors that determines whether or not an individual will disclose is the intended receiver; how the receiver will react and respond and the relationship with the receiver can be critical influences on the discloser. As such, it is imperative that we investigate the experiences of receivers to more comprehensively understand the process of STI disclosure so that we may continue to improve sexual health education and care for all.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/00224499.2024.2343927