Let’s Talk About Sex: PCPs and Men Who Have Sex with Men

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A systematic approach to asking about sexual behavior may help more primary care clinicians identify men who have sex with men (MSM) among their patients, which in turn could help them focus on patients in need of more frequent HIV testing and preventive services.

Those are the findings from a study published online on November 7, 2017 in Preventive Medicine.¹

Research suggests that many PCPs do not ask about the sexual orientation of their patients, even though doing so may encourage patients to open up about their risk behavior. Lack of time and discomfort or uncertainty about discussing sexual behavior may explain avoidance of the topic. However, research also suggests that waiting for patients to start these discussions on their own is inefficient.  About 30% of PCPs may be unaware of the sexual orientation, according to one study.²

A systematic approach--patient questionnaires, for example--may potentially overcome such barriers. However, not much is known about how widely PCPs use such tools in clinical practice.
To explore the issue, researchers analyzed data from a web-based survey of 1008 US PCPs conducted in 2014. Clinicians received $69 for completing the survey, which had a response rate of 74.5%.  Respondents were 73% male, 57% white, 28% Asian, and 2% African American. They had an average age of 46 years and had been practicing medicine for an average of 15.3 years.

The survey assessed whether PCPs used a systematic approach to asking about MSM. Such methods included patient-completed questionnaires or taking a routine verbal sex history. Unsystematic methods included relying on patient disclosure or symptom history to identify MSM status, or not assessing MSM at all.

Key results
• Determination of MSM status:
     o 56% by routine verbal review of sex history
     o 41% by patient disclosure
     o 39% by symptom history
     o 23% by patient-completed questionnaire
     o 9% no assessment
• 66% systematically determined MSM status
• Factors independently associated with a systematic method:
     o Being female: 14% increased odds (aPR = 1.16, CI = 1.06–1.26)
     o Teaching hospital affiliation: 15% increased odds (aPR = 1.15, CI = 1.06–1.25)
     o Routinely screening all patients aged 13–64 for HIV: 29% increased odds (aPR = 1.29, CI = 1.18–1.41)
     o Estimating that ≥6% of their male patients are MSM: 14% increased odds (aPR = 1.14, CI = 1.01–1.30)

Even though most PCP’s in this study indicated they actively determine the MSM status of their patients, over 50% did so using verbal questioning, which is often unstructured and may not consistently assess HIV risk, according to the authors.

“Using a patient questionnaire as part of a routine annual or biannual visit might prove useful to consistently ask and collect such information from all patients. With the incorporation of electronic health records in healthcare settings, a patient questionnaire to properly assess risk for HIV/STD acquisition in its electronic format might be an approach that medical providers could consider,” concluded Pollyanna Chavez, PhD, of the CDC, and colleagues.

The authors mentioned several limitations. The study used an online survey and results may not generalize to all US PCPs. It also relied on self-report. Because providers might report what they would like to do rather than what they actually do, results could be biased. The study could not evaluate whether PCPs determined MSM for all their male patients, or just a portion of them.
Toolkits and educational materials to help providers ask about sexual behavior are available from the CDC (https://stacks.cdc.gov/view/cdc/12303) and the National LGBT Health Education Center (Fenway Institute) and the National Association of Community Health Centers, http://www.lgbthealtheducation.org/wp-content/uploads/COM-827-sexual-history_toolkit_2015.pdf

Take Home Points• Online survey study found that most PCPs in the US actively determine the MSM status of their patients, and that 66% use a systematic method
• Over 50% of PCPs rely on verbal questioning to identify the MSM status of patients, which may be unstructured and inconsistent
• Use of a systematic approach (like patient questionnaires) may help more PCPs identify MSM among their patients, which in turn could help them focus on patients in need of more frequent HIV testing and preventive services

References:

1. Chávez PRG, Wesolowski LG, Peters PJ, et al. How well are U.S. primary care providers assessing whether their male patients have male sex partners? Prev Med. 2017; Nov 7.
2. Petroll AE, Mosack KE. Physician awareness of sexual orientation and preventive health recommendations to men who have sex with men. Sex Transm Dis. 2011;38:63-67.
3. Centers for Disease Control and Prevention. A Guide to Taking a Sexual History. Accessed November 27, 2017.
4. National LGBT Health Education Center (Fenway Institute) and the National Association of Community Health Centers. National LGBT Health Education Center (Fenway Institute) and the National Association of Community Health Centers. Taking Routine Histories of Sexual Health: A System-Wide Approach for Health Centers (Toolkit). Accessed November 27, 2017 at: