Coerced syphilis self-testing among men who have sex with men: a nationwide cross-sectional study in China

Syphilis continues to be an urgent public health issue globally among men who have sex with men (MSM) [1]. Frequent testing plays a significant role in syphilis prevention and control [2]. According to syphilis guideline in China, sexually active MSM should take syphilis test at least once annually and every 3–6 month for MSM who engaged in risky sexual behaviors [3]. However, syphilis testing uptake remains low among MSM in many low- and middle-income countries (LMIC) [2, 4]. Syphilis self-testing provides a private and more convenient alternative to in clinic testing and results are provided quicker than blood test in clinics [5, 6]. Syphilis self-testing is a process whereby a person can get kits from online testing programs and community-based organization programs, then collect a specimen from finger pricking, perform the test, and interpret the syphilis result themselves [7, 8]. However, one unintended consequence is the syphilis self-testing coercion from others (including partners, healthcare providers, friends, etc.).

Coercion is defined as an individual acting without a voluntary consent, as a result of physical and mental compulsion, threats of violence, and excessive control [9, 10]. Previous studies showed that coercive testing for human immunodeficiency virus (HIV) and syphilis was prevalent among MSM and general population in many LMICs in 2011–2016 [8, 11‐14]. Studies conducted among MSM in China, Malawi, and the United States indicated that coerced HIV self-testing (HIVST) can lead to a variety of negative consequences, including unwillingness to take the test again, strained or broken relationships, and the feeling that their human rights have been violated [11, 12, 14, 15]. In recent years, syphilis self-testing has been widely promoted among MSM in China, and can be easily accessed online [8]. A previous study conducted in China found that 48% of MSM who had tested for syphilis used self-testing [8]. However, there is no study on syphilis self-testing coercion. This study aimed to examine the prevalence, pattern and correlates of coerced syphilis self-testing among MSM in China.

Overall, 773 men consented to the survey. Of whom, 59 (8.1%) did not meet the eligibility requirements (13 were female, 2 were younger than 16 years old, 44 men did not engage in anal or oral sex with a man during their lifetime) and 15 duplicated surveys were also excluded. A total of 699 eligible participants from 103 cities of 29 provinces completed this survey, of which, 174 men ever undergone syphilis self-testing during their lifetime, and were finally included in this study. Among those self-testers, 31 men (17.8%) reported ever experiencing syphilis self-testing coercion and 12.6% (22/174) reported a positive result in their most recent syphilis self-test.

Syphilis self-testing can help expand syphilis testing uptake among MSM [5, 6]. The World Health Organization (WHO) declared that HIV and syphilis tests should be voluntary, and coerced testing is never appropriate [16]. Our study suggests that coerced syphilis self-testing was prevalent among MSM in China. This study expands the existing literature by focusing on MSM with syphilis self-testing experience, monitoring for the potential harms and exploring factors associated with coerced syphilis self-testing. Findings from this study have the potential to reduce coerced syphilis self-testing while enhancing syphilis test uptake among MSM.

We found that the syphilis self-testing coercion was prevalent in our sample of MSM in China and about half of coercion happened in hotel. The rate is higher than HIVST coercion reported by the study conducted in 2016 among 1312 MSM in China (8%) [11], Malawi (2.9%) [14] and Uganda (0.0%) [17]. This may be related to the high burden of syphilis among MSM, fear of stigma and discrimination of syphilis infection, and poor communication between sexual partners [18]. We found that the prevalence of syphilis is very high (12.6%) in the sample of MSM that completed the survey. Another qualitative study regarding to pressured HIV testing among Chinese MSM revealed that the desire to develop a relationship and lack of advanced notice of the test were also important factors [12]. Additionally, China’s relatively permissive regulatory environment on self-testing [11], unequal power in intimate relationships [19] and the increasing availability of online syphilis self-testing kits [20] may contribute as well.

We found that MSM who engaged in risky sexual behaviors were more likely to experience syphilis self-testing coercion. This finding is consistent with previous study on HIVST coercion among MSM in China [11]. This might attribute to the following reasons. First, compared with the general population, MSM have a higher willingness of using self-testing as a risk reduction technique to screen sexual partners before sex in order to ensure safe sex, especially for partners with risky behaviors who have a higher burden of syphilis infection, sometimes called “point-of-sex” testing [11]. This may lead to situations where testing is coercive in certain circumstances if their partners refuse [21]. Second, previous studies showed that MSM with high-risk sexual behaviors had lower testing self-efficacy (testing self-efficacy refers to people’s level of confidence to have testing) [22], which could result in a high likelihood of being forced to take the syphilis test. Although there is enthusiasm for using mutual partner testing to promote testing uptake and reduce unprotected sex, future programs supporting point-of-sex testing should also strengthen the monitoring of the probable negative outcomes of test coercion.

We found that the types of coercion before or after syphilis self-testing were mostly verbal and psychological (e.g., verbal abuse, threating to end the relationship), with some physical violence responses (e.g., hitting, kicking). The incidence of different forms of syphilis self-testing coercion was higher than the previous study on HIV self-testing coercion among MSM in United States [15]. Although the use of syphilis self-tests may not increase physical violence harm experienced, verbal and psychological coercion may cause MSM anxiety, stress disorder, depression, and other health complications [23]. Therefore, mental health and supportive services should be strengthened for MSM with experience of coerced syphilis self-testing. A comprehensive support structure is required to connect and coordinate existing mental health services with one another and with healthcare services.

The WHO guideline on HIVST have emphasized the necessity of implementing proper measures to monitor for possible HIVST hazards. Many developed countries have already utilized existing systems or enacted regulatory related policies (such as national health policies to regulate the sale, distribution and use of diagnostics intended for self-testing) to monitor the harms of HIVST, resulting in a reduction in the risk of coercion associated with self-testing [24‐26]. Our study underscores the importance for policies to be in place to monitor for potential harms of syphilis self-testing in China. In addition, multiple studies have suggested that-community engagement, post-testing counselling and effective communication between peers can reduce syphilis self-testing coercion [12, 27, 28].

There are several limitations in this study. First, we did not interview individuals who coerced other participants to take syphilis test in our study. This is critical to investigate the reasons behind coerced syphilis testing in future study. Second, all the information in this study was gathered by voluntary self-report, which may be prone to information bias. Third, the study may have a selection bias because we recruited participants online, MSM recruited online tended to be younger and more educated [29], therefore, online recruitment might underrepresent MSM with lower levels of education. Fourth, since this was a cross-sectional study, relations should be interpreted as associations that might or might not be casual. Fifth, our study recruited participant exclusively online with a relatively small sample size, this may limit the statistical inference and generalizations of the results. However, our empirical generalizability research found that the results were similar when the online survey was quantitatively generalized to a national, cross-sectional survey dataset on MSM in China [7, 8, 30]. And according to a previous study that when sample size is 10 times greater than the number of variables, the power of the result was enough [31].

Our findings have several implications for research and policy. From a research perspective, our study expands the scarce existing data by providing a comprehensive analysis of syphilis self-testing coercion among Chinese MSM. Further research studies will be important to intentionally collect extensive information on syphilis self-testing coercion to provide evidence base for the scalability of syphilis self-testing and take effective interventions to reduce coercion. From a policy perspective, this research can help in the development of related strategies for monitoring and preventing syphilis self-testing hazards. Self-testing coercion is present in both syphilis and HIV self-testing. Hence, it is vital to consider merging the efforts to reduce syphilis and HIV self-testing coercion.

The experience of coerced syphilis self-testing was prevalent among MSM in China. Policies should be in place to monitor and prevent for potential harms associated with syphilis self-testing coercion. Innovative interventions to monitor and reduce coerced syphilis self-testing are necessary among MSM in China.