Young Men's Disclosure of Same Sex Behaviors to Healthcare Providers and the Impact on Health: Results from a US National Sample of Young Men Who Have Sex with Men

Abstract

Many men who have sex with men (MSM) do not disclose their same sex behaviors to healthcare providers (HCPs). We used a series of logistic regression models to explore a conceptual framework that first identified predictors of disclosure to HCPs among young MSM (YMSM), and subsequently examined young men's disclosure of male–male sexual behaviors to HCPs as a mediator between sociodemographic and behavioral factors and three distinct health outcomes [HIV testing, sexually transmitted infection (STI) testing, and human papillomavirus (HPV) vaccination]. We determined the predictors of disclosure to HCPs among YMSM and examined the relationship between disclosure and the receipt of appropriate healthcare services. Data were collected online through a US national sample of 1750 YMSM (ages 18–29 years) using a social and sexual networking website for MSM. Sexual history, STI/HIV screening history, sexual health, and patient–provider communication were analyzed in the logistic regression models. Participants were predominantly white (75.2%) and gay/homosexual (76.7%) with at least some college education (82.7%). Young men's disclosure of male–male sexual behaviors to HCPs was associated with the receipt of all healthcare outcomes in our model. Disclosure was a stronger mediator in HPV vaccination than in HIV and STI testing. Disclosure to non-HCP friends and family, HCP visit in the past year, and previous STI diagnosis were the strongest predictors of disclosure. Young men's disclosure of male–male sexual behaviors to HCPs is integral to the receipt of appropriate healthcare services among YMSM. HPV vaccination is more dependent on provider-level interaction with patients than HIV/STI testing.

Introduction

It has been well established that men who have sex with men (MSM) are at increased risk for many adverse health outcomes. These span the domains of mental health, physical health, and sexual health.^1

–6 These disturbing findings are also echoed in young MSM (YMSM).^7
–9 However, many healthcare providers (HCPs) are unaware that their patients are MSM, or do not regularly take adequate sexual histories to correctly define this population among their patient base.¹⁰ This is particularly concerning when considering that the Centers for Disease Control and Prevention (CDC) has a different set of screening guidelines that apply to MSM.¹¹ This has led to many HCPs not recommending HIV or sexually transmitted infection (STI) screening to MSM patients who fall within the CDC guidelines.¹² Further, recommendations for human papillomavirus (HPV) vaccination of adult men of ages 22–26 years are routine only for MSM and those who are immunocompromised.¹³ Implementation of these clinical practice guidelines depends upon clinicians knowing the sexual orientation of their patients.

In light of the documented hesitancies of HCPs to inquire about same sex experiences, the burden may fall on the patients to disclose their MSM status. Among adult MSM, many have reported discomfort in discussing their same sex behaviors with their HCPs.¹⁴ This has been found as a result of both patient and provider discomfort surrounding communication about homosexuality and sexual behavior.^15,16

Supporting MSM to communicate with HCPs has clear benefits. Men's disclosure of sexual history with men to HCPs has been associated with higher likelihood of receiving appropriate HIV screening among MSM in New York City.¹⁷ Similarly, patient–provider communication regarding STI and HIV prevention among YMSM in metropolitan Detroit was also associated with appropriate HIV and STI testing.¹⁸ Further, the offer to receive HIV testing to MSM is strongly related to disclosing male to male sexual behavior and less than one-third of MSM had been offered HIV screening in a US national sample.¹⁹

Despite these findings related to MSM, there has been little research that focuses on predictors of disclosure to HCPs. This study examines this issue with a national sample of YMSM who were members of an online social and sexual networking website. Specifically, we examined disclosure of same sex sexual behaviors to HCPs as a mediator between sociodemographic and behavioral factors and three distinct health outcomes (HIV testing, STI testing, and HPV vaccination). We purposefully chose young men between the ages of 18 and 29 years to represent the ages concurrent with HPV vaccine catch-up recommendations for males (18–21 years) and for MSM (22–26 years), plus an additional lag of 3 years to account for the time between the issuance of the recommendation and data collection. This study builds on previous analyses of these data that explored HPV vaccine acceptability.²⁰

Methods

All US users between the ages of 18 and 29 years (mean = 22.7, standard deviation = 2.5) of an online social and sexual networking website for MSM were invited to complete an anonymous survey of healthcare utilization, health behaviors, and communication with HCPs. Men who met the age range criteria were emailed an invitation to participate and survey access was open for the next 7 days. Of the 4801 men who opened the recruitment email, a total of 2224 (46.3%) consented to and participated in the study. The following analyses are conducted on a subset of 1751 participants who provided data for all relevant variables, including sociodemographics, sexual behavior history, and items related to patient–provider communication. The sample included men in all 50 US states, the District of Columbia, and Puerto Rico and those who self-identified as homosexual/gay (78%) or bisexual (22%). Men were excluded if sexual history data was missing, if they were of age ≥30 years, and if they reported no sex with a man in the past year. There was no compensation for participation in the survey. All survey measures and protocols were reviewed and approved by the Institutional Review Board of Indiana University.

Measures

Participants were asked to complete sociodemograpic questions assessing age, race, level of education, and insurance status. Measures relating to sexual health history included sexual orientation (homosexual/gay, bisexual, straight/questioning/other); STD diagnosis in the past 2 years (participants were asked to indicate whether they ever had any of the nine (listed) STDs or STD-related conditions in the past 2 years, which was dichotomized to “none” and “one or more”);²¹ relationship status (not in a relationship, in a relationship); gender of sexual partners in the past year (men only, men, and women); searched online for sexual health information (yes, no); STD test in the past year (yes, no); HIV test ever (yes, no); and receipt of any doses of HPV vaccine (yes, no). Items related to general health and healthcare utilization included general health status (excellent, very good, good/fair/poor) and HCP visit in the past year (yes, no). Finally, questions related to disclosure of sexual orientation included level of disclosure (sum of people that participants have told that they are gay or bisexual selected from “nobody, mother, father, other relatives, any straight friend, any coworker, my doctor, any neighbor, anyone else”) and disclosure to HCP (indicated by participants' self-report of disclosure to their HCP).

Statistical analysis

The primary focus of this study was to examine MSM disclosure of same sex sexual behavior as a potential mediator between predictor variables (e.g., STD history, age, relationship status, and health status) and the outcomes of interest: HIV testing, STD testing, and HPV vaccination (see Fig. 1 for conceptual framework). To accomplish this goal, a series of logistic regression analyses were conducted following the conceptual framework. We first assessed the associations between the predictors and MSM disclosure with their HCP. We also examined the association between HCP disclosure and care outcomes. We then re-evaluated the effects of the predictors on each of the outcomes, while adjusting for the disclosure variable in the model. By comparing the changes in significance level for the predictors, with and without the HCP disclosure variable in the model, we were able to establish the mediating effect of MSM HCP disclosure for each predictor variable. The same analytical strategy was used for each of the three outcomes of interest. All analyses are performed by using the SAS version 9.3 (SAS Institute, Cary, NC). p Values <0.05 were considered as statistically significant.

FIG. 1.

Conceptual mediation model. HCP, healthcare provider; HPV, human papillomavirus; MSM, men who have sex with men.

Results

Men in this sample had a mean age of 22.7 years, were primarily white (75%), followed by Latino (10%), black (5%), and Asian/Pacific Islander (5%); most were covered by healthcare insurance (83%). Similarly, most of the participants had at least some college education or higher (83%). Sexual orientation was mostly homosexual/gay (77%) and bisexual (20%), and 86% of men reported having only male sexual partners in the past year, whereas 14% reported both male and female sexual partners. Over 38% of the men disclosed same sex sexual behaviors to their HCPs. Participant characteristics for all variables of interest are reported in Table 1.

Table 1.

Participant Characteristics (n = 1751)

	Mean (SD) or %
Age	22.7 (2.5)
Race
White	75.2
Hispanic/Latino	10.3
African American/black	4.9
Asian/Pacific Islander	4.8
Other	3.9
Education
High school or less	17.3
Some college	43.7
Bachelor's degree or higher	39.0
Sexual orientation
Homosexual/gay	76.7
Bisexual	20.0
Straight/questioning/other	3.3
Insurance status
Yes, any form	83.1
No, uninsured^a	16.9
Health status
Excellent	23.8
Very good	46.9
Good/fair/poor^a	29.3
HCP visit past year
Yes	85.6
No^a	14.4
STD diagnosis past 2 years
None^a	82.0
One or more	18.0
Relationship status
Not in a relationship^a	65.9
In a relationship	34.1
Gender of sexual partner(s) past year
Only men	85.6
Men and women^a	14.4
Searched online for sexual health information
Yes	75.5
No^a	24.5
Level of disclosure
0–9 (range)	4.34 (2.58)
Disclosure to HCP
Yes	38.4
No	61.6
STD test past year
Yes	52.5
No	47.5
HIV test lifetime
Yes	69.0
No	31.0
Any HPV vaccine (one or more doses)
Yes	7.3
No	92.7

Denotes referent category where applicable.

HCP, healthcare provider; HPV, human papillomavirus; SD, standard deviation.

Four of the 10 predictors were found to be associated with MSM HCP disclosure for each of the three outcomes (STD testing, HIV testing, and HPV vaccination). Older age, higher level of disclosure to friends and family, recent STD history, and having a HCP visit in the past year were associated with significantly increased probability of MSM HCP disclosure in all three models.

The mediation analytical results for STD testing are reported in Table 2. Higher level of disclosure to friends and family, recent STD history, HCP visit in the past year, and very good-to-excellent health were associated with increased STD testing. When MSM HCP disclosure was added to the model, there was a similar pattern in the reduction of odds ratios for level of disclosure to friends and family (−57%), HCP visit in the past year (−19%), and STD history (−11%), indicating variable levels of mediation across these variables.

Table 2.

STD Testing as the Outcome

	Association with disclosure (A-C)	Association with STD testing (A-D)	Association with STD testing adjusted for disclosure (A-C-D)
Predictors	OR (95% CI)	OR (95% CI)	OR (95% CI)	% Change in OR
Age	1.17 (1.09–1.25)^a	1.05 (0.998–1.10)
Level of disclosure (number of non-HCP individuals to whom disclosed)	2.70 (2.42–3.00)^a	1.24 (1.18–1.31)^a	1.10 (1.03–1.18)^a	57% decrease
STD history 2 years (yes vs. no)	2.33 (1.54–3.51)^a	3.42 (2.42–4.85)^a	3.16 (2.23–4.50)^a	11% decrease
HCP visit past year (yes vs. no)	5.32 (3.11–9.09)^a	4.52 (3.05–6.71)^a	3.86 (2.59–5.78)^a	19% decrease
Relationship status (in a relationship vs. not)	0.72 (0.51–1.01)	1.25 (0.98–1.61)
Health status
Excellent vs. fair	0.94 (0.59–1.50)	1.69 (1.21–2.37)^a
Very good vs. fair	1.05 (0.71–1.54)	1.29 (0.97–1.71)
Searched online for sexual health information (yes vs. no)	1.07 (0.72–1.58)	1.01 (0.83–1.45)
Insurance status (any insurance vs. no insurance)	1.25 (0.80–1.94)	1.05 (0.76–1.45)
Last year—behaviorally MSM only vs. MSMW	1.28 (0.62–2.64)	1.44 (0.94–2.21)
Sexual orientation (gay vs. not gay)	0.72 (0.38–1.39)	1.12 (0.76–1.66)

Significant at p < 0.05.

CI, confidence interval; HCP, healthcare provider; MSM, men who have sex with men; MSMW, MSM and women; OR, odds ratio.

The mediation analytical results for HIV testing are reported in Table 3. Older age, higher level of disclosure to friends and family, recent STD history, having a HCP visit in the past year, being in a current relationship, and very good-to-excellent health were associated with increased HIV testing. When MSM HCP disclosure was added to the model, there was a reduction of odds ratios for level of disclosure to friends and family (−58%), HCP visit in the past year (−27%), STD history (−14%), and age (−8%). The reductions in odds ratios correspond to the level of mediation for each variable, ranging from substantial mediation for level of disclosure to friends and family to minimal mediation for age.

Table 3.

HIV Testing as the Outcome

	Association with disclosure (A-C)	Association with HIV testing (A-D)	Association with HIV testing adjusted for disclosure (A-C-D)
Predictors	OR (95% CI)	OR (95% CI)	OR (95% CI)	% Change in OR
Age	1.17 (1.09–1.25)^a	1.25 (1.18–1.32)^a	1.23 (1.16–1.30)^a	8% decrease
Level of disclosure (number of non-HCP individuals to whom disclosed)	2.70 (2.42–3.00)^a	1.33 (1.24–1.42)^a	1.14 (1.05–1.24)^a	58% decrease
STD history 2 years (yes vs. no)	2.33 (1.54–3.51)^a	4.29 (3.10–7.04)^a	3.83 (2.32–6.29)^a	14% decrease
HCP visit past year (yes vs. no)	5.32 (3.11–9.09)^a	2.73 (1.89–3.97)^a	2.26 (1.55–3.30)^a	27% decrease
Relationship status (in a relationship vs. not)	0.72 (0.51–1.01)	1.54 (1.15–2.07)^a
Health status
Excellent vs. fair	0.94 (0.59–1.50)	1.49 (1.03–2.16)^a
Very good vs. fair	1.05 (0.71–1.54)	1.63 (1.19–2.23)^a
Searched online for sexual health information (yes vs. no)	1.07 (0.72–1.58)	1.30 (0.96–1.76)
Insurance status (any insurance vs. no insurance)	1.25 (0.80–1.94)	0.98 (0.68–1.41)
Last year–behaviorally MSM only vs. MSMW	1.28 (0.62–2.64)	1.38 (0.87–2.17)
Sexual orientation (gay vs. not gay)	0.72 (0.38–1.39)	1.28 (0.85–1.92)

Significant at p < 0.05.

CI, confidence interval; HCP, healthcare provider; MSM, men who have sex with men; MSMW, MSM and women; OR, odds ratio.

The mediation analytical results for HPV vaccination are reported in Table 4. Higher level of disclosure to friends and family, recent STD history, having a HCP visit in the past year, and searching online for sexual health information were associated with increased receipt of ≥1 dose of HPV vaccine. When MSM HCP disclosure was added to the model, only recent STD history remained significant. The odds ratios for disclosure to friends and family (−73%), HCP visit in the past year (−36%), and STD history (−18%) were again reduced and indicated variable levels of mediation.

Table 4.

Human Papillomavirus Vaccination as the Outcome

	Association with disclosure (A-C)	Association with HPV vaccination (A-D)	Association with HPV vaccination adjusted for disclosure (A-C-D)
Predictors	OR (95% CI)	OR (95% CI)	OR (95% CI)	% Change in OR
Age	1.17 (1.09–1.25)^a	1.02 (0.94–1.12)
Level of disclosure (number of non-HCP individuals to whom disclosed)	2.70 (2.42–3.00)^a	1.26 (1.13–1.40)^a	1.07 (0.93–1.22)	73% decrease
STD history 2 years (yes vs. no)	2.33 (1.54–3.51)^a	2.00 (1.26–3.15)^a	1.82 (1.14–2.89)^a	18% decrease
HCP visit past year (yes vs. no)	5.32 (3.11–9.09)^a	2.82 (1.00–7.94)^a	2.16 (.076–6.17)	36% decrease
Relationship status (in a relationship vs. not)	0.72 (0.51–1.01)	1.81 (1.12–2.93)^a
Health status
Excellent vs. fair	0.94 (0.59–1.50)	1.29 (0.69–2.41)
Very good vs. fair	1.05 (0.71–1.54)	1.36 (0.80–2.31)
Searched online for sexual health information (yes vs. no)	1.07 (0.72–1.58)	2.65 (1.30–5.38)^a
Insurance status (any insurance vs. no insurance)	1.25 (0.80–1.94)	1.45 (0.74–2.85)
Last year—behaviorally MSM only vs. MSMW	1.28 (0.62–2.64)	1.51 (0.65–3.47)
Sexual orientation (gay vs. not gay)	0.72 (0.38–1.39)	0.85 (0.38–1.89)

Significant at p < 0.05.

CI, confidence interval; HCP, healthcare provider; HPV, human papillomavirus; MSM, men who have sex with men; MSMW, MSM and women; OR, odds ratio.

Discussion

We found that YMSM reported high utilization of healthcare, including having a primary care provider, and receiving services, including screenings, in the past year. Having a HCP visit in the past year was the strongest predictor of disclosure of male–male sexual behavior, suggesting that more regular contact with a provider may encourage disclosure. Moreover, disclosure to a HCP predicted receipt of STD testing, HIV testing, and HPV vaccination. In addition, the relationship between disclosure to friends and family with the three healthcare outcomes was strongly mediated by disclosure to a HCP, suggesting that MSM who are comfortable with disclosure to others are also more likely to communicate openly with their HCP.

HIV and STI testing outcomes were less dependent on disclosure than HPV vaccination. This could reflect the public health successes of outreach programming in HIV and STI testing, which casts a wider net and places less emphasis on the provider-level interaction. Also, STD testing and HIV testing may be more routine aspects of healthcare that are carried out regardless of sexual orientation. In contrast, HPV vaccination for MSM may be particularly dependent on individual provider practices, which may explain the greater importance of disclosure for this outcome.

To provide appropriate care, it is critical for providers to take sexual histories of their patients, particularly amid differing recommendations for screening and vaccination for MSM compared with their non-MSM counterparts.^22

–25 As long as the Advisory Committee on Immunization Practices only routinely recommends HPV vaccination for 22- to 26-year-old males if they are MSM or immunocompromised, it places unique responsibility on HCPs to create an environment in which disclosure is encouraged.²⁵

Our findings are consistent with those reported by Tai et al.,²⁶ who showed that MSM disclosure to a provider was associated with gonorrhea and syphilis testing. In addition, disclosure of sexual identity to primary care providers was seen by LGBT patients to be as challenging as coming out to others, but was mitigated by a good therapeutic relationship.²⁷ Taken as a whole, our findings and the findings of these additional studies suggest strongly that HCPs need to promote a culture of openness, regardless of their own sexual orientation or beliefs. In a related vein, changes in policy (workplaces, etc.) and increasing acceptance of sexual diversity may improve appropriate provision of health services and care for MSM. A positive effect of this shift in social norms toward greater acceptance of sexual diversity could be the reduction in future morbidity and mortality for sexual health-related conditions.

A primary limitation of this study is the cross-sectional design, which does not allow for conclusive evidence of temporal associations. However, the consistency between our findings and those of other research suggests that disclosure may, in fact, predict subsequent improved healthcare delivery for MSM. In addition, although our sample was not representative of the US population of MSM, we had representation from all 50 states. Moreover, given that these men were recruited using a social and sexual networking website, they may represent a more behaviorally high-risk sample than MSM in general and are a relevant sample for examination of receipt of sexual health-related care. However, it is worth noting that black males, the group at highest risk for HIV/STI acquisition, were underrepresented in our sample.²⁸ Finally, it is likely that there are other variables involved in disclosure that we were not able to measure in this national study. Research has indicated that not all HCPs can provide the same level of care to MSM at risk for HIV or with HIV, and that HCP attitudes toward at-risk men may be involved.^29,30 More research is needed to further understand how disclosure differs across HCPs, and to better understand HCP attitudes specifically toward YMSM who are at risk for HIV/STIs.

Footnotes

Acknowledgment

This study was funded by Merck Investigator Studies Program No. 39801 from Merck and Company, Inc. (Stupiansky, PI).

Author Disclosure Statement

No competing financial interests exist.

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