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Psychiatric, legal, and moral issues of herpes simplex infections
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Psychiatric, legal, and moral issues of herpes simplex infections Peter J. Lynch, M.D. Minneapolis, MN When patients first realize that they have genital herpes, they are likely to have a series of psychiatric reactions that include (1) denial, (2) a belief that there is a cure, (3) realization that they do have herpes, (4) loneliness, (5) anger toward their sexual partners, (6) fear of sexual deprivation, and (7) development of a poor self-image. One of the best coping mechanisms is to develop a social support system. Despite many concerns about sexual activities, the patient's work performance often goes on as before. By 1985, law suits by'patients against those who allegedly gave them herpes had not resulted in awards at the Appeals Court level and one malpractice suit against physicians was not awarded. Genital infections in children must be regarded as potential child abuse by physicians. Morally, it is right for an infected person to disclose the existence of herpes to a potential partner but this is not always done for fear of compromising a relationship in its early phases. Because one's original infection may be asymptomatic, relating the time of acquisition of an infection to an act of infidelity cannot be judged solely on the basis of the time of the herpetic breakout. (J AM ACAD DERMATOL 1988; 18:173-5.)
The same problems we have faced with patients infected with herpes over the years are now surfacing, but with more intensity, in patients with immunodeficiency syndrome. These are difficult areas to talk about because there is so little published in the way of scientific studies and our individual experience is heavily biased and hard to quantitate. However, in an attempt to maintain objectivity, this report is based on a survey of the medical literature and a computer search of recent legal decisions. In the psychologic area the first good material was the article by Luby and Gillespie 1 in 1981 describing a syndrome of what is likely to go through the minds of individuals when they first realize that they have genital herpes. They have a series of psychiatric reactions that include (1) ini-
F r o m the D e p a r t m e n t of D e r m a t o l o g y , School o f Medicine.
University of M i n n e s o t a
tial shock with some features of denial, (2) a belief that there is a cure and that if they see enough physicians, they will find it, (3) eventual realization that they do have genital herpes and for this reason are now isolated individuals different from the rest of society, (4) loneliness and the realization that they have problems ahead of them, (5) the recognition that they might not have herpes if it had not been for their sexual partners with resultant anger directed toward their partners, (6) fearing the consequences of sexual deprivation as a result of the communicability of their infection, and (7) development of a poor self-image with onset of depression. A recent study 2 examined the coping mechanisms for people with psychiatric reactions to herpes. A psychiatrist studied about 150 people who were recruited from self-help groups and by means of community advertising. Some felt that there was something innate about themselves or that there was something happening to them that 173
174
Lynch
was beyond their control and thus they were not personally to blame for acquiring herpes. This mechanism of coping was associated with a bad psychiatric result. Some blamed themselves but recognized that what led to the infection was a modifiable behavior pattern and they would change their behavior in the future. This turned out to be a healthy coping mechanism. Some chose wishful thinking, believing that the infection would not have occurred had they done something differently; this was a poor coping mechanism. Negative thoughts that focused on the bad aspects of herpes such as its permanence, recurrence rate, and contagiousness were associated with poor results. The best coping mechanism of all was found to be the development of a social support system. Luby and Klinge 3 conducted a questionnaire study of 74 patients with genital herpes in 1985. These patients had evidence of depression, a sense o f helplessness, and a sense o f victimization. In women there was long-range concern about the development of cervical cancer and the problems that they might have to face during childbirth. A major part of the study concerned the potentially adverse effects herpes would have on sexual activity. Approximately one half to three quarters of the patients had reduced sexual pleasure, inhibited sexual freedom, impaired spontaneity, decreased sexual frequency, and marked concern about spread o f the disease to their partners. The exact incidence of impotence in men was not indicated but it was viewed as a devastating problem. There was surprisingly little evidence that the herpetic infection affected the patient's behavior in nonsexual areas. Their work performance went on about as it had before. Most of the rest of the literature was anecdotal. Bierman 4 has written some articles that help to downplay the hysteria associated with herpes. His approach is useful in countering the pessimism of the lay press and can be used directly in the counseling of patients.5 Stress is an enhancer o f recurrent disease. One prospective study indicated that patients with high anxiety titers, especially those obsessed by the presence of their disease, had greater recurrence rates.6 Some short reports have suggested that psychotropic agents such as lithium and benzodiaze-
Journal of the American Academy of Dermatology
pine reduce recurrence rates, but this may have been no more than a placebo effect. In questionnaires patients almost always identify stress as the single most important factor that influences recurrence rates. There are also legal problems. Two lawsuits concerned women who claimed that their male consorts had given them herpes. In both cases the Appeals Court sent them back to the local level without resolution. Two of the reasons that the law suits had been successful initially were the legal doctrines that one must conform to a certain standard of conduct that will protect others against acquiring a disease and that when there is a risk one is required to identify the risk if it is substantial and likely to lead to contagion. The reason these lawsuits were rejected at the appeals level was probably related to problems with proof. The patient would have to prove that she had no other sexual partners and that she was an "immunologically naive" person exposed to herpes for the first time during contact with the defendent. She would also have to prove that significant harm was done and, of course, there is appreciable medical question about just how serious genital herpes is. There was an additional case in which a divorced mother lost custody of a child because she developed herpes. The case was decided on the basis that acquisition of herpes indicated that she was promiscuous and unfit to be a mother. Most lawsuits are, of course, processed at a lower level than the appeals court and for this reason never get to the legal computer bank. As a result this larger experience is not available for our study. What about herpes in malpractice actions against physicians? Only one such case had reached the appeals level. The correct diagnosis was made but the plaintiff claimed that a dangerous treatment, dye plus light, was used that could cause cancer. However, malpractice was not found because dye plus light was considered to be an acceptable therapy .at the time this case was adjudicated. Another potential problem concerns child abuse. Physicians are under legal obligation to report evidence of child abuse, including sexual
Volume 18 Number 1, Part 2 January 1988
Psychiatric, legal, and moral issues of herpes simplex 175
abuse. Genital herpetic infections in children come under this category. In another legal case a woman was reportedly gang raped by a number of young men. She developed herpes, which was felt to be proof that the alleged assault did in fact take place even though examination at the time of the incident failed to reveal sperm in the vagina. Finally, a potential legal problem that has not been carefully examined revolves around libel such as saying publicly that someone has herpes, an accusation that could be viewed as defamation. There are also moral problems with herpetic infections. There is a moral responsibility that an infected person disclose his or her status to a current or future sexual partner. Almost all people with herpes believe that full disclosure is desirable and necessary, yet only about 50% of infected persons practice disclosure. Obviously, disclosure would best be carded out early in a relationship but this is rarely done for fear of compromising further development of that relationship. Waiting until the very last seconds before intercourse may not be morally (or legally) acceptable because it could be argued that meaningful consent had not been given. A second moral problem has to do with the timing of intercourse when a person has had herpes. When can the patient safely have intercourse without infecting his or her partner? I believe that barrier methods, specifically condoms, will prevent infection of the man from asymptomatic cervical shedding. The use of a condom in the man should also protect the woman from asymptomatic shedding in the man from the urethra or glans. Of course shedding in both sexes from other sites would still be potentially infectious. An important unanswered question is whether taking acyclovir on a regular basis will reduce asymptomatic shedding to a point where the patient is at no risk of spreading the disease. Prophylactic acyclovir may eliminate symptomatic disease, but does this mean that there is no asymptomatic shedding of virus? Whether it is safe to have intercourse during the prodrome is a question that comes up frequently
in m y practice. Most patients develop a prodrome of several hours before the development o f clinical lesions. It is not known how often contagion is possible during this time, but it has been reported. Another question is whether two people, both with histories of herpes, can safely have intercourse with each other. We recognize that it is possible to transmit a new strain of herpes to someone who is already infected, although there is probably some minor protection provided by the initial infection. What about the moral attitudes of a person whose partner has developed herpes? Is it correct to assume that the partner has been promiscuous or recently unfaithful? Certainly not. A certain proportion of first clinical episodes of herpes occurs as a result of reactivation of previously acquired infecton that was never clinically expressed at the time of acquisition. Thus a newly, clinically infected sexual partner did not necessarily acquire the herpes within the usual incubation period of 2 weeks or so. The sexual partner may have acquired the infection months or years before. In other words, sexual infidelity cannot be judged on the basis of the time o f a herpetic breakout. Because a person develops herpes, we should not assume that he or she is a less desirable partner from the standpoint of a long-range or marital relationship. It is not morally defensible to reject a relationship solely on the basis of herpes, although this probably happens. Finally, what about "pillow talks" about friends who have herpes. This certainly is not morally prudent and borders on defamation. REFERENCES
1. Luby ED, GillespieO. Psychologicalresponses to genital herpes. Helper 1981;3:2-3. 2. Manne S, Sandier I. Coping and adjustment to genital herpes. J Behav Med 1984;7:391-410. 3. Luby ED, Klinge V. Genital herpes: a pervasive psychosocial disorder. Arch Dermatol 1985;121:494-7. 4. Bierman SM. Recurrentgenital herpes simplex infection: a trivial disorder. Arch Dermatol 1985;121:513-7. 5. Connor-GreenePA. The role of counselingin the treatment of genital herpes. J Am Coll Health 1986;34:286-7. 6. Goldmeir D, Johnson A. Does psychiatric illness affect the recurrence rate of genital herpes? Br J Vener Dis 1982;58:40-3.
III
III II I
I
II
II
II I
Psychiatric, legal, and moral issues of herpes simplex infections Peter J. Lynch, M.D. Minneapolis, MN When patients first realize that they have genital herpes, they are likely to have a series of psychiatric reactions that include (1) denial, (2) a belief that there is a cure, (3) realization that they do have herpes, (4) loneliness, (5) anger toward their sexual partners, (6) fear of sexual deprivation, and (7) development of a poor self-image. One of the best coping mechanisms is to develop a social support system. Despite many concerns about sexual activities, the patient's work performance often goes on as before. By 1985, law suits by'patients against those who allegedly gave them herpes had not resulted in awards at the Appeals Court level and one malpractice suit against physicians was not awarded. Genital infections in children must be regarded as potential child abuse by physicians. Morally, it is right for an infected person to disclose the existence of herpes to a potential partner but this is not always done for fear of compromising a relationship in its early phases. Because one's original infection may be asymptomatic, relating the time of acquisition of an infection to an act of infidelity cannot be judged solely on the basis of the time of the herpetic breakout. (J AM ACAD DERMATOL 1988; 18:173-5.)
The same problems we have faced with patients infected with herpes over the years are now surfacing, but with more intensity, in patients with immunodeficiency syndrome. These are difficult areas to talk about because there is so little published in the way of scientific studies and our individual experience is heavily biased and hard to quantitate. However, in an attempt to maintain objectivity, this report is based on a survey of the medical literature and a computer search of recent legal decisions. In the psychologic area the first good material was the article by Luby and Gillespie 1 in 1981 describing a syndrome of what is likely to go through the minds of individuals when they first realize that they have genital herpes. They have a series of psychiatric reactions that include (1) ini-
F r o m the D e p a r t m e n t of D e r m a t o l o g y , School o f Medicine.
University of M i n n e s o t a
tial shock with some features of denial, (2) a belief that there is a cure and that if they see enough physicians, they will find it, (3) eventual realization that they do have genital herpes and for this reason are now isolated individuals different from the rest of society, (4) loneliness and the realization that they have problems ahead of them, (5) the recognition that they might not have herpes if it had not been for their sexual partners with resultant anger directed toward their partners, (6) fearing the consequences of sexual deprivation as a result of the communicability of their infection, and (7) development of a poor self-image with onset of depression. A recent study 2 examined the coping mechanisms for people with psychiatric reactions to herpes. A psychiatrist studied about 150 people who were recruited from self-help groups and by means of community advertising. Some felt that there was something innate about themselves or that there was something happening to them that 173
174
Lynch
was beyond their control and thus they were not personally to blame for acquiring herpes. This mechanism of coping was associated with a bad psychiatric result. Some blamed themselves but recognized that what led to the infection was a modifiable behavior pattern and they would change their behavior in the future. This turned out to be a healthy coping mechanism. Some chose wishful thinking, believing that the infection would not have occurred had they done something differently; this was a poor coping mechanism. Negative thoughts that focused on the bad aspects of herpes such as its permanence, recurrence rate, and contagiousness were associated with poor results. The best coping mechanism of all was found to be the development of a social support system. Luby and Klinge 3 conducted a questionnaire study of 74 patients with genital herpes in 1985. These patients had evidence of depression, a sense o f helplessness, and a sense o f victimization. In women there was long-range concern about the development of cervical cancer and the problems that they might have to face during childbirth. A major part of the study concerned the potentially adverse effects herpes would have on sexual activity. Approximately one half to three quarters of the patients had reduced sexual pleasure, inhibited sexual freedom, impaired spontaneity, decreased sexual frequency, and marked concern about spread o f the disease to their partners. The exact incidence of impotence in men was not indicated but it was viewed as a devastating problem. There was surprisingly little evidence that the herpetic infection affected the patient's behavior in nonsexual areas. Their work performance went on about as it had before. Most of the rest of the literature was anecdotal. Bierman 4 has written some articles that help to downplay the hysteria associated with herpes. His approach is useful in countering the pessimism of the lay press and can be used directly in the counseling of patients.5 Stress is an enhancer o f recurrent disease. One prospective study indicated that patients with high anxiety titers, especially those obsessed by the presence of their disease, had greater recurrence rates.6 Some short reports have suggested that psychotropic agents such as lithium and benzodiaze-
Journal of the American Academy of Dermatology
pine reduce recurrence rates, but this may have been no more than a placebo effect. In questionnaires patients almost always identify stress as the single most important factor that influences recurrence rates. There are also legal problems. Two lawsuits concerned women who claimed that their male consorts had given them herpes. In both cases the Appeals Court sent them back to the local level without resolution. Two of the reasons that the law suits had been successful initially were the legal doctrines that one must conform to a certain standard of conduct that will protect others against acquiring a disease and that when there is a risk one is required to identify the risk if it is substantial and likely to lead to contagion. The reason these lawsuits were rejected at the appeals level was probably related to problems with proof. The patient would have to prove that she had no other sexual partners and that she was an "immunologically naive" person exposed to herpes for the first time during contact with the defendent. She would also have to prove that significant harm was done and, of course, there is appreciable medical question about just how serious genital herpes is. There was an additional case in which a divorced mother lost custody of a child because she developed herpes. The case was decided on the basis that acquisition of herpes indicated that she was promiscuous and unfit to be a mother. Most lawsuits are, of course, processed at a lower level than the appeals court and for this reason never get to the legal computer bank. As a result this larger experience is not available for our study. What about herpes in malpractice actions against physicians? Only one such case had reached the appeals level. The correct diagnosis was made but the plaintiff claimed that a dangerous treatment, dye plus light, was used that could cause cancer. However, malpractice was not found because dye plus light was considered to be an acceptable therapy .at the time this case was adjudicated. Another potential problem concerns child abuse. Physicians are under legal obligation to report evidence of child abuse, including sexual
Volume 18 Number 1, Part 2 January 1988
Psychiatric, legal, and moral issues of herpes simplex 175
abuse. Genital herpetic infections in children come under this category. In another legal case a woman was reportedly gang raped by a number of young men. She developed herpes, which was felt to be proof that the alleged assault did in fact take place even though examination at the time of the incident failed to reveal sperm in the vagina. Finally, a potential legal problem that has not been carefully examined revolves around libel such as saying publicly that someone has herpes, an accusation that could be viewed as defamation. There are also moral problems with herpetic infections. There is a moral responsibility that an infected person disclose his or her status to a current or future sexual partner. Almost all people with herpes believe that full disclosure is desirable and necessary, yet only about 50% of infected persons practice disclosure. Obviously, disclosure would best be carded out early in a relationship but this is rarely done for fear of compromising further development of that relationship. Waiting until the very last seconds before intercourse may not be morally (or legally) acceptable because it could be argued that meaningful consent had not been given. A second moral problem has to do with the timing of intercourse when a person has had herpes. When can the patient safely have intercourse without infecting his or her partner? I believe that barrier methods, specifically condoms, will prevent infection of the man from asymptomatic cervical shedding. The use of a condom in the man should also protect the woman from asymptomatic shedding in the man from the urethra or glans. Of course shedding in both sexes from other sites would still be potentially infectious. An important unanswered question is whether taking acyclovir on a regular basis will reduce asymptomatic shedding to a point where the patient is at no risk of spreading the disease. Prophylactic acyclovir may eliminate symptomatic disease, but does this mean that there is no asymptomatic shedding of virus? Whether it is safe to have intercourse during the prodrome is a question that comes up frequently
in m y practice. Most patients develop a prodrome of several hours before the development o f clinical lesions. It is not known how often contagion is possible during this time, but it has been reported. Another question is whether two people, both with histories of herpes, can safely have intercourse with each other. We recognize that it is possible to transmit a new strain of herpes to someone who is already infected, although there is probably some minor protection provided by the initial infection. What about the moral attitudes of a person whose partner has developed herpes? Is it correct to assume that the partner has been promiscuous or recently unfaithful? Certainly not. A certain proportion of first clinical episodes of herpes occurs as a result of reactivation of previously acquired infecton that was never clinically expressed at the time of acquisition. Thus a newly, clinically infected sexual partner did not necessarily acquire the herpes within the usual incubation period of 2 weeks or so. The sexual partner may have acquired the infection months or years before. In other words, sexual infidelity cannot be judged on the basis of the time o f a herpetic breakout. Because a person develops herpes, we should not assume that he or she is a less desirable partner from the standpoint of a long-range or marital relationship. It is not morally defensible to reject a relationship solely on the basis of herpes, although this probably happens. Finally, what about "pillow talks" about friends who have herpes. This certainly is not morally prudent and borders on defamation. REFERENCES
1. Luby ED, GillespieO. Psychologicalresponses to genital herpes. Helper 1981;3:2-3. 2. Manne S, Sandier I. Coping and adjustment to genital herpes. J Behav Med 1984;7:391-410. 3. Luby ED, Klinge V. Genital herpes: a pervasive psychosocial disorder. Arch Dermatol 1985;121:494-7. 4. Bierman SM. Recurrentgenital herpes simplex infection: a trivial disorder. Arch Dermatol 1985;121:513-7. 5. Connor-GreenePA. The role of counselingin the treatment of genital herpes. J Am Coll Health 1986;34:286-7. 6. Goldmeir D, Johnson A. Does psychiatric illness affect the recurrence rate of genital herpes? Br J Vener Dis 1982;58:40-3.