Patients, providers, and prevention: comprehensive sexual health care for YMSM

Chelsea

Last month at the Adolescent Health Conference in Ypsilanti, Michigan, I presented a poster about patient-provider sexual health discussions and the uptake of HIV and sexually transmitted infection (STI) testing for young men who have sex with men (YMSM) aged 13-29. YMSM are at a much higher risk for HIV as well as STIs like chlamydia and gonorrhea than the general population.[i] My presentation examined how the interactions between YMSM and their medical providers impacted subsequent testing for HIV or other STIs. Unsurprisingly, the results of our study show that men who have had any discussion of sexual health behavior or risk prevention with a health provider were substantially more likely to have been tested for HIV and other STIs in the prior year. Our study also revealed that knowledge of testing locations and comfort discussing sexual behaviors were strong predictors of these comprehensive sexual health screenings.

The findings of our study reinforce previous research supporting the potential power of patient-provider interactions to improve preventive sexual health for YMSM. Perhaps more importantly, these results show that YMSM who have discussions with their providers about sex are more likely to test not only for HIV, but for other STIs as well. In fact, nearly two-thirds of our respondents had been screened for HIV and at least one other STI.  In many ways, these findings make sense: having a discussion with a doctor or medical provider about sexual health should correlate with higher HIV/STI testing rates for YMSM, who experience dramatic STI disparities. And yet, for more than a third of our respondents, preventive sexual health screenings occurred only for HIV or not at all. This is a troubling indicator given the extensive research establishing that the presence of asymptomatic STIs like chlamydia and gonorrhea increase vulnerability to HIV while at the same time increasing the infectiousness of those already living with HIV.[ii]

New guidelines under the Affordable Care Act have greatly expanded free preventive screening services for HIV and STIs among people with health insurance.[iii] However, these services are only free for patients at higher risk, which means that accessing free, comprehensive sexual health services could require YMSM to come out to their providers.[iv]  As a result, limitations to increasing sexual health screenings during routine wellness screenings for YMSM are substantial. Primarily, the burden on YMSM to disclose their sexual orientation will prevent those who feel unsafe coming out to their medical providers from accessing free services.[v] Likewise, by their own admission, most medical providers are inadequately trained to take routine sexual health histories from the LGBT community to screen for sexual health risks.[vi]  Finally, many providers still hold discriminatory views toward the LGBT community, and toward gay or bisexual men in particular [vii]. The vast majority of states uphold the legality of this discrimination through “conscience” or “refusal” clauses that allow providers—including doctors, nurses, or other medical staff-to cite religious beliefs as a basis for denying care to LGBT patients.[viii]

Ultimately, though we found evidence that sexual health discussions positively influenced HIV and other STI testing rates for YMSM, these findings coincide with continued barriers to health services for this population. Moving forward, policies will need to address the lack of LGBT cultural competence among health providers while at the same time integrating sexual health issues beyond HIV into routine wellness screenings. These screenings should not place the burden on patients to self-disclose their identities and behaviors, but health providers should instead initiate sexual health discussions. Lastly, the patient-provider setting will only become a safe intervention space for YMSM if individuals do not fear reprisal or denial of services for coming out.  By practicing cultural humility [ix], medical providers can help to assure YMSM that they will not face discrimination for disclosing their identities. YMSM deserve to be welcomed, and not merely tolerated, by their health providers.

References

[i] Rieg, G., Lewis, R. J., Miller, L. G., Witt, M. D., Guerrero, M., & Daar, E. S. (2008). Asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies.AIDS patient care and STDs22(12), 947-954.

[ii] Cohen, M. S. (2003). HIV and sexually transmitted diseases: lethal synergy.Topics in HIV medicine: a publication of the International AIDS Society, USA,12(4), 104-107.

[iii] HealthCare.gov. (2014). What are my preventive care benefits? Retrieved from https://www.healthcare.gov/what-are-my-preventive-care-benefits/.

[iv] HealthCare.gov. (2014). What are my preventive care benefits? Retrieved from https://www.healthcare.gov/what-are-my-preventive-care-benefits/.

[v] Hoffman, N. D., Freeman, K., & Swann, S. (2009). Healthcare preferences of lesbian, gay, bisexual, transgender and questioning youth. Journal of Adolescent Health45(3), 222-229.

[vi] Matharu, K., Kravitz, R. L., McMahon, G. T., Wilson, M. D., & Fitzgerald, F. T. (2012). Medical students’ attitudes toward gay men. BMC medical education,12(1), 71

[vii] Matharu, K., Kravitz, R. L., McMahon, G. T., Wilson, M. D., & Fitzgerald, F. T. (2012). Medical students’ attitudes toward gay men. BMC medical education,12(1), 71

[viii] Ponce NA, Cochran SD, Pizer JC, et al. The effects of unequal access to health insurance for same-sex couples in California. Health Affairs. 2010;29(8):1-10. See also http://www.apa.org/pi/lgbt/resources/policy/conscience-clause-brief.aspx

[ix] Tervalon, M., Murray-Garcia, J. (1998).  Cultural humility versus cultural competence: A critical distinction in defining physical training outcomes in multicultural education.  Journal of Health Care for the Poor and Underserved, 9(2), 177-125.

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