Among men who have sex with men (MSM) in the United States, rates of sexually transmitted diseases (STDs) are high and continue to increase.1,2 Thus, the Centers for Disease Control and Prevention (CDC) recommend that sexually active MSM be screened for chlamydia, gonorrhea, and syphilis at least annually and every 3 to 6 months, if at increased risk.3,4 Furthermore, for chlamydia and gonorrhea, the recommendations include screening at anatomical sites of contact, regardless of condom use. Therefore, on at least an annual basis, medical care providers need to know (1) the sex/gender of their patient's sexual partners, (2) number and type (main, casual) of sexual partnerships, (3) factors that increase risk of STD acquisition and transmission (such as sex without a condom, multiple sex partners, anonymous sex partners, sex under the influence of drugs or alcohol), and (4) types of sex in which their patients are engaging (oral, anal) and sexual role (receptive, insertive). This necessitates that medical care providers collect sexual history information to determine which STD tests to administer. The purpose of this study is to generate national estimates of STD-related care among US MSM as related to the CDC STD MSM-specific recommendations. The rates of STD are higher among young MSM and black and Hispanic MSM.1 Young, black, and Hispanic MSM are also less likely to have access to health care.5 Therefore, we also examined differences in STD-related care by age and race/ethnicity, as disparities in STD-related care might partly explain disparities in STD rates in these key populations.
MATERIALS AND METHODS
We analyzed data from the National Survey of Family Growth, a national household probability sample of people in the United States between the ages of 15 and 44 years from 2011 to 2015 and between 15 and 49 years from 2015 to 2017, with oversamples of adolescent, Hispanic, and non-Hispanic black respondents.6 Data were collected from September 2011 to September 2017. The survey is administered in-person with a portion administered through audio computer-assisted self-interview. The response rate for men was 72% in 2011 to 2013, 67% in 2013 to 2015, and 64% in 2015 to 2017, with a sample size of 13,861 for 2011 to 2017. The National Survey of Family Growth was approved by the National Center for Health Statistics research ethics review board.
We restricted the analysis to sexually active MSM (age, 15–44 years) who reported sex with a man in the past 12 months, for a sample size of 435. The health care access measures included current type of health insurance, whether at any time they were not covered by health insurance in the past 12 months, whether they had a usual place for health care, and, if so, whether they had gone to their usual place for health care in the past 12 months. The sexual risk assessment measures included whether the respondents reported their doctor or other medical care provider had asked them about the following topics in the past 12 months: their sexual orientation or sex of their sex partners, their number of sex partners, their condom use, and the types of sex that they have (whether it be vaginal, oral, or anal). For the receipt of STD-related health services, we examined whether the respondents had been tested for an STD in the past 12 months and, if so, whether they had been tested in their pharynx or rectum (i.e., extragenital testing), and treated or received medication for an STD. The categorization of MSM for inclusion in this analysis, sexually activity, sexual risk assessment, and STD-related health services were from the audio computer-assisted self-interview portion of the survey.
For the analysis, we used SAS-callable SUDAAN 11.0.1, to account for the complex sampling, where survey weights were used to approximate the US population of 15- to 44-year-olds.6 We used χ2 tests of association to find differences in health care access, sexual risk assessment by a provider, and use of STD-related health services based on age (15–24 and 25–44 years) and race/ethnicity (Hispanic, non-Hispanic white, and non-Hispanic black). The age groups were determined by the high burden of STDs among 15- to 24-year-olds and restricted to age 44 years to be consistent with the first 4 years of data collection. For the race/ethnicity analysis, people who identified as something other than Hispanic, non-Hispanic white, and non-Hispanic black were not included in race/ethnicity-stratified analyses but were included in the total and age analyses. χ2 Tests of association were also used to compare the sexual risk assessments by a provider with having been tested for an STD in the past 12 months and whether they had been tested in their pharynx or rectum.
Overall, 80.7% of sexually active MSM in the United States had current health insurance coverage and 61.1% had private health insurance (Table 1). However, 27.7% of sexually active MSM did not have health insurance coverage at some time in the past 12 months and 19.2% were currently uninsured. Most sexually active MSM (82.0%) reported a usual place for health care, and 77.5% of those men had gone to their usual place in the past 12 months.
For sexual risk assessment, only 34.8% of sexually active MSM were asked about their sexual orientation or sex of partners in the past 12 months by a doctor or other medical care provider (Table 1). Similarly, only 30.0% were asked about their number of sex partners, 39.8% were asked about their condom use, and 31.6% were asked about the types of sex that they had. Less than half (45.8%) of sexually active MSM had been tested for STDs in the past 12 months, of whom more than half (58.0%) were tested at their pharynx or rectum, and 12.7% of sexually active MSM reported zthat they had been treated for an STD in the past 12 months. None of the results for health care access, sexual risk assessment by a provider, and use of STD-related health services significantly differed by age.
By race/ethnicity, we found a significant association by sexually active MSM being asked by a doctor or other medical care provider in the last 12 months about condom use and the types of sex they had (Table 1). Nearly twice as many non-Hispanic black and Hispanic MSM were asked about their condom use (black, 61.1%; Hispanic, 50.4%; white, 31.0%; P < 0.001) and types of sex (black, 48.0%; Hispanic, 41.3%; white, 24.1%; P < 0.01) compared with non-Hispanic white MSM. Sexually active MSM did not significantly differ by race/ethnicity on the other measures.
In addition, there were significant associations (P < 0.01) among sexually active MSM having been tested for STDs in the past 12 months by the sexual risk assessments (not reported in Table 1). For whether a doctor or other medical care provider asked the respondent about sexual orientation or sex of partners, number of sex partners, condom use, or type(s) of sex, the proportion of MSM tested for STDs ranged from 72.9% to 79.4%. For extragenital STD testing of sexually active MSM in the past 12 months, the sexual risk assessments ranged from 72.8% to 77.0%.
This first national survey analysis of health care access and receipt of recommended STD-related services by MSM has revealed important gaps. Among sexually active MSM in the United States, many lack access to health care and too few receive sexual risk assessments and STD screening including extragenital testing. Although most sexually active MSM had current health insurance, there were more than twice as many MSM who were uninsured compared with the general population during the surveyed time (2011–2017).7–9 The CDC recommends risk assessment questions as part of the clinical prevention guidelines, which can help them determine which services to recommend based on the answers for each patient.4 However, only 30% to 40% of sexually active MSM self-reported sexual risk assessments conducted by health care providers in the past 12 months, whereas 9% to 17% of all sexually active men reported some amount of sexual risk assessment, suggesting that MSM are more likely to be asked these questions by providers.10 Contrary to the CDC's STD screening guidelines, most sexually active MSM were not screened for STDs, especially non-Hispanic white MSM. Although the screening guidelines specify that MSM should be screened at anatomic sites of sexual contact, very few MSM were receiving extragenital testing, suggesting that infections may be missed. Furthermore, evidence suggests that it may be important to screen MSM for STDs at all 3 anatomic sites, regardless of reported sexual behaviors.11,12
It is unknown if medical care providers who see sexually active MSM are aware of the CDC's STD screening guidelines, how they determine if their patients are at increased risk (and therefore in need of more frequent screening), or how and when to screen at sites of contact. From a study of providers who are members of the Sexual Medicine Society of North America, the providers who asked about sexual orientation were more likely to inquire about more sexual behaviors and tailor care to sexual minority's needs.13
Limitations of this study include the lack of data from health care providers, the imprecision of measurement related to the timing and type of health care visits (e.g., for something other than sexual health-related issues), and the small numbers of MSM in our sample, which limits our ability to examine more complex models of receipt of sexual health services by MSM or to look at temporal trends from 2011 to 2017.
Although there are differences in STD rates among MSM in the United States by age and race/ethnicity, we did not find differences in health care access, sexual risk assessment by health care providers, or STD-related health services, except for more black and Hispanic MSM being asked about condom use and types of sex by their providers compared with white MSM. Future research is needed to identify the factors that prompt health care providers to take sexual histories and follow the recommended STD screening guidelines for MSM. Interventions to increase health care access and STD-related care for MSM may be helpful. In addition, interventions focusing on the patient level (self-screening for STDs), provider level (provider detailing by experts in STD care), and structural level (emergency medical response–based solutions to implement CDC guidelines in practice) may help to stem the tide of increasing STDs among this priority population.
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