Health care access, health care utilisation and sexual orientation disclosure among Black sexual minority men in the Deep South

Keywords: HIV, sexual health, sexually transmissible infection (STI), stigma.

Black gay, bisexual, and other sexual minority men, referred to collectively as Black sexual minority men (BSMM),^1,2 account for the greatest disparities in HIV-related outcomes in the US.³ Estimates suggest that at current trends in HIV prevention, treatment and care, 50% of BSMM will acquire HIV in their lifetime.⁴ The US South, where most BSMM reside, consistently reports the highest HIV diagnoses and AIDS-related deaths of any region in the US.^5,6 HIV incidence among BSMM is highest in the Deep South, in states such as Georgia and Mississippi,^7–9 where 50% of US BSMM were diagnosed.⁵ Health care access, health care utilisation and disclosing sexuality to providers are important factors for HIV prevention and treatment and in the care of BSMM.^10–12

‘Health care access’ generally refers to the feasibility of obtaining needed medical services and includes having health insurance, affordable copayments and primary care providers.¹³ Health care utilisation is the use of services for the treatment of conditions such as HIV and sexually transmissible infections (STIs).¹⁴ For BSMM, health care access, health care utilisation and disclosing sexuality to providers are affected by structural factors such as limited transportation, a lack of health insurance coverage and discrimination based on race and sexual orientation.^11,15,16 Factors such as younger age, HIV serostatus and gender identity also limit sexuality disclosure for BSMM.^11,12,15

In addition, having distrustful attitudes towards the healthcare system contributes to lower utilisation of HIV prevention, treatment and care services among BSMM.^10,17,18 BSMM report greater negative experiences when receiving care,^11,15 have higher levels of anticipated discrimination when seeking care¹⁸ and report higher levels of medical mistrust and lack of confidentiality from medical services¹⁹ than heterosexual men. BSMM in urban contexts are less likely than White sexual minority men to disclose their sexual orientation or same-sex sexual behaviours to healthcare providers,²⁰ which creates suboptimal healthcare experiences and facilitates HIV incidence.

Sexual minority men (SMM) who disclose their sexual orientation to their healthcare providers are more likely to be exposed to HIV prevention information and receive HIV prevention services such as HIV testing than those who do not.^20,21 However, some BSMM avoid disclosing their sexual identity or same-sex sexual behaviours in primary care settings and instead use emergency rooms because they require less engagement with providers than outpatient settings.^18,22 Healthcare providers who are unaware of the sexual orientation or same-sex sexual behaviours of their SMM patients provide fewer recommended sexual health screening and preventive services for this highly marginalised population.^20,23 Despite evidence of distrust of healthcare providers among BSMM,^11,15,16 few studies have quantified the correlates of sexuality disclosure among BSMM in the Deep South.

Although some studies have explored the role of sexual identity disclosure on awareness of HIV prevention methods among BSMM,^12,24 few have explored the relationship between sexual identity disclosure to healthcare providers on health care access and utilisation among BSMM in the Deep South. To fill this gap, this study examined the prevalence and associations between sexual orientation disclosure to healthcare providers and health care access and utilisation among BSMM in the Deep South.⁵ We hypothesised that openness of sexual orientation with healthcare providers will be associated with greater utilisation of primary care services and greater use of HIV and STI prevention services. Findings from this research could better inform relevant policy and prevention strategies for this vulnerable population in the US Deep South.

Data were derived from a well-documented population-based cohort study locally initiated in Jackson, Mississippi, and Atlanta, Georgia, and known locally as The MARI Study, from July 2013 and December 2014 to identify multilevel correlates of HIV risk among BSMM. Details of the study design and procedures have been published elsewhere.^14,25,26 Briefly, participants were recruited using a combination of active and passive recruitment strategies. Active recruitment included direct contact with individuals at community events, local bars and clubs frequented by BSMM, as well as at community-based activities hosted by the study partner organisations (Open Arms Healthcare Center in Jackson; AID Atlanta and NAESM in Atlanta). Passive recruitment involved posting advertisements on social networking websites such as Facebook and geospatial networking apps (i.e. Jack’d), at local colleges and universities, bars and clubs and community-based organisations that service BSMM. Inclusion criteria required a self-report of Black or African American race, male sex at birth, age ≥18 years and engaging in oral or anal sex with another man in the 6 months before study enrolment. Participants who reported being HIV uninfected or unaware of their status at study enrolment underwent rapid HIV testing, after risk reduction counselling, by certified research staff. Participants aware of their HIV infection (previously diagnosed HIV infected) signed a release of health information authorisation form to confirm their serostatus.

The study protocol was approved by the Sterling Institutional Review Board in Atlanta, GA, and all participants provided written informed consent.

Disclosure of sexual orientation with healthcare providers was assessed using the question, ‘When you interact with a healthcare person, how open are you with them about your sexual orientation?’ Response options included: (1) ‘very open, I tell them about my sexual orientation’; (2) ‘somewhat open, I may tell them about my sexual orientation if they ask’; and (3) ‘not open at all, I won’t tell them about my sexual orientation’.

Responses for two items, namely ‘During the last 12 months, did you have any kind of healthcare coverage?’ and ‘In the past 12 months, did you have a primary health care provider?’, were used to asses health care access. Responses were dichotomous (yes or no). Participants were also asked about the type of healthcare coverage or insurance used to pay for medical care in the past 12 months. Response options for healthcare coverage or insurance type included public insurance (i.e. Medicare, Medicaid and the military, Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), TriCare or Veterans Affairs (VA)), private insurance (i.e. from employer or workplace, college or school, private health insurance plan purchased directly or parents’ insurance plan) or something else.

Three domains were used to assess health care utilisation: (1) primary care; (2) STI prevention and testing; and (3) HIV prevention and testing.

Primary care utilisation was assessed using the item, ‘During the past 12 months, did you see a doctor, nurse, or other health care provider for any reason?’ STI prevention and testing was assessed using the following items: ‘During the past 12 months, did a doctor, nurse, or other health care provider ask you about or give you advice regarding prevention of STIs?’, ‘During the past 12 months, did a doctor, nurse, or other health care provider ask you about or give you advice regarding testing for STIs?’ and ‘In the past 12 months, were you tested for a sexually transmitted infection?’. HIV prevention was assessed using the item, ‘During the past 12 months, did a doctor, nurse, or other healthcare provider ask you about or give you advice regarding HIV prevention?’ and HIV testing utilisation was assessed using two items, namely ‘During the past 12 months, did a doctor, nurse, or other health care provider ask you about or give you advice regarding HIV testing?’ and ‘Over the past two years, how many times did you get tested for HIV?’. Except for the last question, for which the response options were ‘once’, ‘twice’ and ‘three or more times’, all responses options were dichotomous, yes or no.

Participants were asked to self-report age, which was used a continuous variable.

Participants were asked to self-identify their sexual orientation from a range of categories and were then were classified as ‘homosexual/gay’, ‘bisexual’ or ‘other’ (for those identifying as straight or heterosexual or as none of the categories listed).

Participants were asked to indicate their typical sexual position during anal sex with male partners: ‘top’, ‘bottom’, ‘versatile’ or ‘other’.

Gender non-conformity was assessed using two items: (1) ‘How do you think people would describe your appearance, style, or dress?’; and (2) ‘How do you think people would describe your mannerisms?’.²⁷ Response options were scored on a seven-point scale ranging from 1, ‘very feminine’, to 7, ‘very masculine’ (Cronbach’s α = 0.93).

Participants who self-reported being HIV negative were given a rapid HIV test at baseline to confirm their HIV status. The HIV status of participants who self-reported living with HIV was confirmed by a review of medical records. Participants were categorised as ‘living with HIV’, which included previously and newly diagnosed BSMM, or ‘HIV negative’.

All statistical analyses were performed using SAS 9.3 (SAS Institute, Cary, NC, USA). Chi-squared tests and two-sample t-tests were used to explore differences in sexual orientation disclosure by demographic and other selected covariates. Poisson regression models with robust standard errors were used to estimate prevalence ratios (PR) between sexual orientation disclosure to healthcare providers and health care access and utilisation. We estimated distributions of selected covariates across categories of openness of sexual orientation with healthcare providers and estimated P-values for trends across ordered categories by including openness of sexual orientation as an ordinal variable (i.e. coded as 1–3) in unadjusted linear and logistic regression models. Multivariable models were adjusted for age, HIV status, ethnicity, transgender identity, sexual orientation, typical position during sex and gender non-conformity. Models related to HIV prevention and testing were limited to HIV-uninfected individuals. There was no evidence of multicollinearity among variables within models (variance inflation factor <5).

In all, 465 BSMM were enrolled in the MARI Study in 2014; 79 were excluded because of unusable audio computer-assisted self-interview data, missing sexual orientation disclosure information or missing information on all healthcare access and utilisation measures, leaving 386 in the analytical sample. The mean (±s.d.) age of participants was 30.5 ± 11.2 years; 35.3% were previously diagnosed with HIV and 3.7% were newly diagnosed with HIV. Two-thirds (67.2%) self-identified as homosexual or gay and 70.6% reported being very open regarding their sexual orientation with their healthcare providers. Regarding insurance, 43.8% reported having health insurance and 45.2% reported having a primary healthcare provider in the past 12 months (Table 1).

Table 1.  Selected baseline sociodemographic characteristics among Black sexual minority men in the Deep South, 2013–14 (n = 386)
Unless indicated otherwise, data are given as n (%). Asterisks indicate variables where sample responses contain missing data. STI, sexually transmissible infection

Bivariate results between sexual orientation disclosure to providers and sociodemographic characteristics among BSMM are given in Table 2. Sexual orientation and typical sexual position during anal sex were significantly associated with sexuality disclosure. Specifically, those who reported being very open about their sexual orientation with healthcare providers had a greater prevalence of identifying as homosexual or gay than those who identified as bisexual or ‘other’ (P < 0.001). In addition, there was a greater prevalence of reporting sexual position during anal sex as ‘top’ among those who reported not at all disclosing sexuality (P = 0.049). There were no significant differences in the prevalence of HIV or any other sociodemographic characteristics relative to sexual orientation disclosure to providers.

Table 2.  Selected baseline sociodemographic characteristics by categories of sexual orientation disclosure with healthcare providers among Black sexual minority men (BSMM)
Unless indicated otherwise, data are given as percentages. †, Marginally statistically significant; *, P < 0.05; ***, P < 0.001

Table 3 describes the multivariate regression analyses examining the associations of openness of sexual orientation with healthcare providers with measures of health care access and utilisation. In multivariate models, compared with BSMM who were very open about their sexual orientation, BSMM who were somewhat open or not at all open about their sexual orientation with their healthcare provider had a lower prevalence of visiting a healthcare provider for any reason in the past 12 months (PR 0.48 (95% confidence interval (CI) 0.28–0.80) and 0.42 (95% CI 0.18–0.97) respectively; graded trend P = 0.006). In addition, BSMM who were somewhat open and not at all open about their sexual orientation with their healthcare provider were less likely than those who were very open to have a lower prevalence of being advised on the prevention of and testing for STIs in the past 12 months (PR 0.27 (95% CI 0.11–0.66) and 0.28 (95% CI 0.12–0.69) respectively for the not at all open group). In addition, compared with BSMM who were very open about their sexual orientation, BSMM who were somewhat open or not at all open about their sexual orientation with their healthcare provider had a lower prevalence of being advised on the prevention of (PR 0.56 (95% CI 0.33–0.97) and 0.34 (95% CI 0.14–0.80) respectively) and testing (PR 0.40 (95% CI 0.17–0.96 for the not at all open group) for HIV. No consistent associations were observed between openness of sexual orientation with healthcare providers, health care access (health insurance status, type of health coverage or having a primary healthcare provider) and STI or HIV testing.

Table 3.  Multivariable prevalence ratios of the associations between sexual orientation disclosure with healthcare providers and health care access and utilisation among Black sexual minority men (SMM) after adjusting for age, ethnicity, transgender identity, sexual orientation, position during sex and gender non-conformity (the MARI Study, 2013–14)
Unless indicated otherwise, data show prevalence ratios with 95% confidence intervals in parentheses. The ‘very open’ group was used as the reference group throughout. *P < 0.05, **P < 0.01 compared with very open. STI, sexually transmissible infection

This study explored the prevalence and correlates of sexuality disclosure to healthcare providers among BSMM in the Deep South. Sexual orientation and typical sexual position during anal sex were associated with level of openness of sexual orientation to healthcare providers. Sexuality disclosure to healthcare providers was also associated with health care utilisation, STI prevention healthcare services and HIV prevention healthcare services. Contrary to our hypothesis, level of openness was not associated with health care access. Improved patient–provider communication in the healthcare setting could mitigate the HIV epidemic among BSMM in the Deep South.

We found that typical sexual position during anal sex was associated with sexuality disclosure among BSMM in the Deep South. This is a notably novel finding and calls for future research into this association, because risks for HIV and STIs vary by sexual positioning practices.^28,29 Specifically, SMM who practice receptive anal intercourse are at greater risk for HIV and rectal STI infection than those who only practice insertive anal intercourse.²⁸ Because background HIV and STI prevalence is high among BSMM,^30–32 discussing sexual orientation and sexual positioning practices with providers is crucial to ensuring proper screening and treatment for potential infections.^33–35 Sexual positioning practices could be an added source of stigma for some BSMM^36–39 and an important factor related to disclosure in the context of healthcare settings. In the US Deep South, where same-sex attraction is very stigmatised,^5,40 stigma related to sexual positioning practices could exacerbate suboptimal communication between healthcare providers and BSMM.

BSMM who self-identified as gay were more likely to report being very open about their sexual orientation to healthcare providers than those who self-identified as bisexual or other. This finding is consistent with prior research that found that gay men are more likely to disclose their sexual orientation to healthcare providers. For instance, Durso and Meyer found that gay men and lesbian women were more likely to disclose their sexual orientations to healthcare providers than bisexual men and women.⁴¹ Similarly, a study containing a racially diverse sample of SMM in New York City found that most who identified as gay reported disclosing their sexual orientation to healthcare providers, whereas no SMM who identified as bisexual or straight reported disclosing their sexual orientation to healthcare providers.²⁰

Sexual orientation disclosure was also associated with accessing and using HIV and STI prevention services among BSMM in the Deep South. These findings are consistent with other research showing that disclosing sexual orientation to primary care physicians is associated with screening recommendations targeted towards SMM, such as HIV testing, hepatitis A vaccinations and hepatitis B vaccinations.⁴² In addition, a study by Ng et al. found that, among a sample of SMM in Vancouver, Canada, participants who had disclosed their sexual orientation to healthcare providers were more likely to have been tested for HIV, hepatitis C virus, gonorrhoea and syphilis, and were more likely to have ever been vaccinated against hepatitis A and hepatitis B.²³

Although there is a burgeoning body of research regarding disclosure of sexual orientation in healthcare settings, most studies include samples of predominately White men. In addition, few studies have evaluated the associations of disclosure to healthcare providers among BSMM in the Deep South, where HIV is the most concentrated. Findings from the present study offer essential preliminary data regarding the associations of disclosure of sexual orientation to healthcare providers for this marginalised population. The findings suggest that the healthcare setting is a multidimensional experience that could potentially mitigate the HIV epidemic among BSMM. Our results also suggest that special interventions targeting subpopulations of BSMM may be essential in the treatment, care and prevention of HIV. For example, our results suggest there are differences in disclosure to healthcare providers by sexual orientation and sexual position.

The present cross-sectional study is not without limitations. This study is not generalisable to BSMM throughout the Deep South or the US. In addition, this study did not assess medical mistrust, perceived discrimination in healthcare settings and past healthcare experiences. This study did not assess healthcare provider characteristics, such as sex, age and race, which are known to affect Black patients’ comfort.¹¹ Third, this investigation did not examine differences between rural and urban areas. Finally, we did not assess traditional barriers to health care access and utilisation, such as lack of transportation, distance between residence and healthcare providers and a perceived lack of quality of health care. Although these are potential limitations, the focus of the MARI Study was to identify multilevel correlates of sexual behaviours among BSMM in the Deep South.

To the best of our knowledge, this is one of the first investigations to examine the associations between disclosure of sexual orientation to healthcare providers and multiple measures of health care access and utilisation among BSMM in the Deep South. Clinics, hospitals and other healthcare settings should promote affirming behaviours and environments that welcome all people, regardless of race, ethnicity, sexual orientation or sexual behaviours. Equally, healthcare providers should directly ask participants about sexual behaviours and provide culturally appropriate services.

The authors report no conflicts of interest.