Objectives: To investigate psychological functioning, relationship factors, stigma perception, disclosure outcomes and regret about the disclosure decision in people being treated for anogenital warts, comparing disclosers and non-disclosers and evaluating the possible predictors of disclosure.
Method: A self-completion questionnaire was completed by 54 participants recruited from a London genitourinary medicine clinic. There were 36 disclosers and 18 non-disclosers.
Results: Disclosers were significantly less anxious than non-disclosers (p<0.01). Compared with non-disclosers, disclosers also rated their relationships as longer lasting (p<0.001) and closer (p<0.01). Disclosers were less likely to express regret about their disclosure decision than were non-disclosers (p<0.001). There were no significant differences between groups with regard to depression, self-esteem, expected partner response to disclosure, or sexually transmitted infection (STI)-related stigma perception, although there was a trend towards higher stigma perception in disclosers (p = 0.15). The actual partner response to disclosure was significantly more supportive than had been expected (p<0.001). A binary logistic regression model used three variables to predict disclosure status with an accuracy of 83%. Disclosers were predicted by lower anxiety levels, longer relationship duration and higher stigma perception.
Conclusions: Relationship factors, in particular duration, were key predictors of partner disclosure of anogenital warts. In terms of individual characteristics, only anxiety was significantly different in disclosers and non-disclosers. Perceptions of stigma and expected outcome of disclosure were not significantly different in the two groups. Of particular relevance to those considering whether or not to disclose, partner response was significantly more supportive than disclosers expected and disclosers expressed significantly less regret about their disclosure decision than did non-disclosers.
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Much less is known about the psychological impact of anogenital warts than is known about other sexually transmitted infections (STI) such as herpes or HIV. The psychosocial effects of anogenital warts have a much greater impact on wellbeing than the physical effects.1 Such information as is available suggests that people with anogenital warts experience increased anxiety and depression and elevated rates of relationship and sexual difficulties.2–5 Fear of a negative partner response to disclosure has been identified as a major and recurrent source of anxiety for people with anogenital warts.2 6
Infection with the types of human papillomavirus (HPV) associated with anogenital warts is very common, it is often asymptomatic and it is not medically harmful.7 Asymptomatic infections do not require treatment and may not be infectious.7 Therefore, UK national guidelines suggest that although current partners may benefit from assessment, partner notification strategies are not required for anogenital warts, nor is the tracing of previous partners recommended.8
Considering what factors might be relevant to the disclosure decision, one study suggested that disclosure of warts was more likely in longer-term than casual relationships.9 This is consistent with research in genital herpes populations.10 It might also be predicted that those who expect a worse partner response to disclosure might be less likely to disclose. Another study, however, reported no association between disclosure and the anticipated negative consequences of disclosure.11 The researchers suggested that fear of a negative response was not a critical barrier to disclosure and that other factors, such as the nature of the relationship and self-efficacy, were more important.11 Finally, although it might be expected that those who view having anogenital warts as more stigmatising might be less likely to disclose, there is no direct evidence to support or refute this. Such an effect has, however, been found in research with HIV populations.12
We set out to research people being treated for anogenital warts in a genitourinary medicine clinic. We compared those who had disclosed to their partners with those who had not disclosed in terms of psychological functioning, perception of STI-related stigma, relationship factors, expected partner response and regret about the disclosure decision. When participants had disclosed to their partner, expected and actual partner responses were compared. We also asked participants directly to give the reasons why they had (or had not) disclosed.
After we obtained ethical approval from Brent Medical Ethics Committee, participants were recruited from a busy north London genitourinary medicine clinic. Patients were eligible for the study if they had a diagnosis of anogenital warts, were not known to have HIV infection, were aged over 16 years, and had had a sexual relationship since the first diagnosis whether this was a continuation of a previous relationship or a new relationship. Clinic staff referred appropriate patients to the researcher. Ninety per cent of these patients consented to take part in the research.
We recruited a total of 54 participants, including 36 whose partners knew about their warts (disclosers) and 18 whose partners did not know (non-disclosers). The sample included 38 men and 16 women. All participants reported that their current partner was of the opposite sex. When asked about ethnicity, 57% described themselves as white, 30% as black and 13% as Asian. The median age was 27 years and the median time since first diagnosis with HPV was 2 years: 37% were diagnosed within the past year, 45% 1–5 years ago and 18% more than 5 years ago.
We collected all data by self-report questionnaire. In addition to basic demographic data, information on time since diagnosis and the number of recurrences was collected. The Hospital Anxiety and Depression Scale (HADS)13 and Rosenberg’s Self-Esteem Scale14 were used to assess psychological functioning. Perceived STI-related stigma was assessed using a scale developed by Cunningham et al.15 For our sample on this scale, Cronbach’s alpha was 0.92, suggesting high internal reliability and consistency.
Participants were asked to rate their current or most recent relationship for closeness and length and to select whether they viewed their relationship as casual, long-term, or were not sure. They were asked to rate how they expected, or had expected, their partner to respond when they found out about the warts. If they had disclosed, they were asked to rate how their partner had actually responded. These ratings were collected using a series of five-point Likert scales from “extremely negatively” to “extremely supportively”. Disclosers were also asked to report how, if at all, their relationship had changed after disclosure.
The Pearson χ2 was used to compare differences in proportions for categorical variables. The Student’s t-test was used to analyse normally distributed continuous variables. The non-parametric Mann–Whitney U-test was used for continuous variables that were skewed. For multivariate analysis, a binary logistic regression model was applied. Data were analyzed using SPSS version 12 (SPSS Inc, Chicago, Illinois, USA). The primary research question compared the psychological functioning of disclosers and non-disclosers, using a between-subjects two-tailed t-test. Using a power of 0.80, alpha of 0.05 and a 50% disclosure rate gave a minimum planned sample size of 50.16
Of the 54 participants, 67% had disclosed and 33% had not disclosed. No significant differences were found between disclosers and non-disclosers with respect to any of the demographic or disease-related variables, although there was a trend towards disclosers being older than non-disclosers (p = 0.09).
Using a cut-off of eight for the total sample 6% of participants could be defined as cases on the HADS depression subscale compared with 33% on the anxiety subscale. These results are consistent with levels expected in the general population.17 Self-esteem scores on the Rosenberg’s Self-Esteem Scale ranged from 24 to 40, with a mean of 34, also consistent with levels expected in the general population.18
The reasons given by respondents for telling or not telling partners are shown in decreasing order of frequency (table 1). Participants could select reasons from a list or use free form entry to add any reasons not listed. Honesty and concerns about transmission were the most common reasons cited for disclosure. Participants reported not disclosing mostly because they were too embarrassed or because they thought that their partner might respond negatively.
Using the HADS, the mean anxiety level of disclosers was 4.7 (normal), whereas the mean anxiety level of non-disclosers was 8.2 (mild). The anxiety of non-disclosers was thus significantly greater than that of disclosers (t = −3.04, p<0.01). Both closeness of relationship and length of relationship were greater for disclosers than for non-disclosers (U = 161, p<0.01; U = 132, p<0.001). Disclosers were less likely than non-disclosers to rate their relationship as casual (Fisher’s exact test 19.6, df 2, p<0.001). Regret about the disclosure decision in non-disclosers was greater than that in disclosers (U = 37, p<0.001). There were no significant differences in depression (t = −0.86, p = 0.39), self-esteem (t = 0.87, p = 0.39) or STI-related stigma perception (t = 1.46, p = 0.15) of disclosers and non-disclosers. The expected partner response of disclosers was the same as that of non-disclosers, with both on average expecting “neutral” responses (t = −0.15, p = 0.89). The actual partner response was better than the expected partner response (t = −4.79, p<0.001).
After disclosure, 19 out of 33 participants considered that their overall relationship was the same in terms of closeness, compared with 12 who considered that their relationship was closer and only two who considered that it had become somewhat less close. Out of 32 participants, 21 reported that their partner’s response to disclosure stayed the same over time. A further 10 reported that their partner had become more supportive, whereas only one reported that their partner had become less supportive over time. Considering the 23 participants who did not disclose until after first having sexual intercourse, only two reported that their partner was less interested in sex after disclosure, with four reporting that the sexual relationship was less spontaneous and seven that sex was less frequent. Whereas participants attributed the changes to their disclosure, a natural decline in both spontaneity and frequency of sex might be expected in the early months of a new relationship. Although there were insufficient numbers to allow statistical analysis, a review of responses suggests that the actual partner response may have been better when the partner was told in a planned manner than when the partner was told on impulse.
A binary logistic regression analysis predicted disclosure status with an overall accuracy of 83% (constant only model 69%). The overall model was significant in its predictive ability (Nagelkerke R2 = 0.68, p<0.001; table 2). Disclosure was predicted by having a relationship regarded to be long term, by low levels of anxiety and by high levels of stigma perception.
Our findings suggest that people whose partners do not know about their warts experience significantly more anxiety than those whose partners do know.
In our study, after the disclosure of warts, partners were significantly more supportive than the disclosers had expected.
We also found that people who told their partners about their warts were less likely to regret their disclosure decision than those who had not told their partners.
The best predictors of disclosure status were the relationship variables: people in longer-term, closer relationships were more likely to have disclosed to their partners than those in casual relationships.
Our findings suggest that a high level of STI-related stigma perception is not a barrier to disclosure.
To our knowledge, this is the first report comparing the psychological functioning of disclosers and non-disclosers in an anogenital wart population.
Disclosers reported significantly lower anxiety than non-disclosers (p<0.01). It is possible that non-disclosure leads to greater anxiety because of the fear of discovery.19 It could be, however, that greater anxiety leads to the avoidance of disclosure. Both could, of course, be true if anxiety leads to non-disclosure, which in turn leads to greater anxiety.
There was no significant difference between disclosers and non-disclosers in terms of the level of perceived stigma associated with having warts. Considering STI with more serious medical consequences, it is often suggested that higher levels of stigma are associated with reduced disclosure rates. We did not find this to be so in our study of anogenital wart disclosure. We observed a trend towards higher stigma perception in disclosers compared with non-disclosers. If this trend is supported by further research, it might suggest that those with low stigma perception understand that HPV infection is very common, and view anogenital warts as not medically serious and perhaps not worth mentioning to partners. Indeed, other research has found that people who know that HPV infection is very common report lower levels of stigma perception than those who do not know that HPV is common.20
Intrarelationship factors were more relevant to the disclosure decision than perceptions of stigma. Disclosure was significantly more likely in closer and longer-lasting relationships. In this respect the results are similar to those for herpes disclosure.10
In this study, disclosers and non-disclosers did not differ in their expectations of partner response: overall, both groups expected a neutral response. Nevertheless, 71% of non-disclosers gave concerns about partner reaction as a reason for non-disclosure. In other areas of human decision-making about health, it is not simply the mean judgement that determines behaviour: confidence in the accuracy of judgement and consideration of the “worst case scenario” are also important.21 It is possible that those who did not disclose felt either less certain of their partner’s likely response or less able to risk a more negative reaction. This would be consistent with greater disclosure in longer-term relationships if people in such relationships felt better able to judge their partner’s likely reaction accurately.
Actual partner response was significantly more supportive than disclosers expected and disclosers expressed significantly less regret about their disclosure decision than did non-disclosers, both issues of direct relevance to people with anogenital warts considering whether or not to tell their partners.
Although there was a low refusal rate among those who had the study explained to them, an unknown number of patients could not be engaged. Second, the quantitative methodology may have limited the range of reasons given for disclosure and non-disclosure. Although respondents could add their own reasons as free text, we cannot be sure that we represented the full range of possible reasons people may have had for disclosure or non-disclosure. Finally, this study involved participants from an ethnically diverse population in north-west London. Whereas the research questions were based on theory and on previous research that has recruited participants from a variety of STI populations and settings, it is still possible that findings may not generalise to other populations.
The authors would like to thank the patients and staff at the clinic for their support.
Contributors: LS led the data analysis and writing. JG and GB contributed to writing the paper and critically reviewing each draft. JG helped to analyse and interpret the data. JH contributed to the conceptualisation of the research.
Competing interests: None.
Ethics approval: Ethical approval was obtained from the Brent Medical Ethics Committee.
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