Identifying MSM-competent physicians in China: a national online cross-sectional survey among physicians who see male HIV/STI patients

Globally, men who have sex with men (MSM) are at elevated risk of HIV acquisition, other sexually transmitted infections (STIs), substance abuse, and mental health disorders [1‐4]. In many low- and middle-income countries (LMICs), MSM face significant barriers to accessing health care [5, 6]. MSM in LMICs report stigma, discrimination, and ignorance of health services as major barriers to health care provision [7, 8]. In addition, MSM have reported negative interactions with physicians, such as providers who did not ask or disapproved of same-sex practices, did not provide sexual health counseling or HIV/STI testing services, or revealed their sexual orientation to others [9].

HIV prevalence among MSM in China has increased from 6.0% in 2010, to 8.0% in 2015 [10]. It was estimated that the lifetime HIV testing for MSM is 47%, and that 18% of them didn’t retrieve their results [11]. The infection risk of STIs was significantly higher in MSM compared to the general population [12]. The rapid spread of HIV and STIs among MSM has led to renewed efforts to improve health services for MSM [13]. However, Chinese policy towards MSM is ambiguous (no approval, no disapproval and no promotion) and same-sex marriage is illegal. In China, there is a lack of laws to protect MSM from discrimination and unfair treatment. Experienced and anticipated health discrimination is widely reported by MSM and is also a barrier for MSM to use health services (including HIV testing) in China [14, 15]. In one cross-sectional study of MSM in China, only 16.3% had disclosed their sexual orientation to any health care professional [16], lower than in high-income countries [17, 18]. Incompetent health care providers also delay the testing and services of HIV and STIs for MSM. Provider-initiated HIV testing services is an effective way to increase the uptake of HIV testing [19]. But in China, STI care providers offered HIV testing to only 28.4% of their patients [20]. In addition to providing HIV/STI testing services, physicians serving MSM are responsible for obtaining a thorough sexual history, discussing sexual practices, partners, and conducting an appropriate physical examination [15, 21]. But these services were not common practice among Chinese physicians [20]. In qualitative studies, MSM in China have indicated the importance of knowledgeable, confidential, gay-friendly physicians in accessing sexual health services [22]. Furthermore, physicians need the material resources necessary to provide appropriate care for MSM, such as condoms, lubricants, and sexual health information for patients [23].

MSM-competent health services are seen as a key component in HIV and STI prevention programs, which offers MSM comprehensive sexual health services including health promotion, counselling, peer support, prevention, adequate diagnostics and treatment. It provides health care that is sensitive to the special needs of MSM and encourages them to obtain health care services and disclosure sexual orientation to health providers [24]. Health providers, including physicians and nurses, need education and training to be able to deliver competent services. However, there is a lack of competency training among China’s health providers to provide more appropriate routine care and remove barriers for MSM to get appropriate services [20].

Physicians’ clinical competency to serve MSM has been overlooked in HIV and STI prevention programs. In order to inform the development of MSM-competent clinical care, we conducted a survey among Chinese physicians who have provided STI care to men. Given that it is difficult to evaluate the physicians’ competency in a comprehensive way, our study focused on their clinical behaviors. In this study, we adopted the definition of MSM-competent physicians from other original research as those who self-reported having asked their last male STI patient about sex with other men, anal sex, and recommended both HIV and syphilis testing [25]. We also assessed the physicians’ workplace information, their attitudes towards MSM and their willingness in future training to explore factors that correlate with competency.

A total of 8089 physicians received the participation link, and 1556 physicians clicked the survey link and entered the survey, of which 699 provided informed consent. Among physicians who consented, 186 did not meet eligibility criteria, and another 12 surveys were invalidated due to insufficient information. A total of 501 physicians were included in the final analysis.

This study explores clinical competency and attitudes toward MSM among an online sample of physicians in China. This study contributes to the limited literature on clinical services for MSM in China by examining clinical competency in serving MSM patients and attitudes among physicians who see male STI patients. We found that most physicians reported asking about sexual orientation, recommending STI testing, and asking about anal intercourse in their last clinical encounters. We also found that most physicians were willing to attend MSM-focused clinical training and openly identify as physicians willing to see MSM.

Over 60% of physicians who reported seeing MSM STI patients met basic criteria for MSM competency. Our results showed that the percentage of asking about same-sex sexual practices was higher than a previous study in China, which reported only 11% of the physicians asked their patients occasionally or most of the time [20]. The percentage of physicians asking about sexual practices is lower than that reported in high-income country studies focused on physicians who see patients with sexual health concerns [33, 34]. In our study, nearly all physicians reported recommending HIV/syphilis testing for their last STI patient. Although there are no comparable data for HIV testing among HIV/STI patients, research showed that a lower percentage of US physicians reported offering HIV testing. Among general practitioners in the US whose patients were general population, 41.7% of the physicians offered HIV testing [35]. Among HIV care providers whose patients were partly HIV infected, 60% routinely offered HIV testing to their patients [36]. Further studies should be conducted to investigate outcomes when physicians are seeing general patients and explore factors associated with patients accepting HIV testing offered by physicians in China.

MSM-competent physicians practiced in a wide range of clinical settings and medical subspecialties. Although some studies have found higher quality STI care in subspecialist clinics [37, 38], we did not observe significant differences in MSM competency between subspecialists and general practitioners. Additionally, MSM-competent physicians were associated with institutional factors (providing condom, lubricants, STI prevention pamphlets or educational materials), rather than individual factors. Recommendations of educational materials are recommended in guidelines for HIV prevention and LGBT patients, reinforcing the office-based education effect [39]. Guidelines for care of LGBT patients state that LGBT patients often find clues to determine what information they are comfortable to share with health care providers [40]. The educational and prevention material may have a potential effect on the interaction between physicians and STI patients. In addition, these materials may be the results of the institutional support for sexual health issues and risk population, which have a positive effect on physicians’ competency. Provision of educational and prevention material can play a useful role in an MSM competency improvement program.

Physician clinical competency and attitudes are both critical toward engaging MSM in care. In our study, most physicians reported positive attitudes towards MSM, although based on individual statement alone, most physicians reported neutral attitudes. Our finding contrasts with previous Chinese research from 1101 physicians showing negative physician attitudes toward MSM and widespread discrimination [41]. The more inclusive societal attitudes towards LGBT population showed from a recent national survey may influence health providers’ attitudes [42]. We found no correlation between the physicians’ MSM competency and attitudes towards MSM, indicating the disjunction between clinical practice and personal attitudes. However, it is the practical competency and non-judgmental attitude that work together to optimize MSM’s well-being. Physicians in China need both training to improve clinical practice and reduce stigma to better serve the MSM population.

We also found that most physicians were willing to receive further training to better serve MSM. Training and education initiatives to improve knowledge, attitudes, and clinical competencies among physicians for serving MSM patients is essential to improving the health of sexual minorities [43]. In LMICs, increased capacity from training in providing non-stigmatizing and non-discriminatory services to MSM patients can improve clinical outcomes [44, 45]. The high interest in our study suggests that subsequent MSM training may be feasible. Further research is needed to find the effect of training interventions or programs for physicians to improve their clinical practice and attitudes towards MSM.

The study has several limitations. First, the study was based on physician self-report, introducing the potential for social desirability and recall bias [46]. Physicians were asked about their last patients to reduce the likelihood of the recall bias, but responses related to competent clinical practice and willingness to contribute to MSM services might be over reported due to the social desirability bias. However, self-report surveys have been widely used in the studies with physicians [33, 34, 37, 47], allowing a reasonable comparison to the literature. Second, we used a narrow definition of MSM-competency that focuses on physicians’ clinical practice. Another limitation of the definition is the lack of patients’ voice and experience of the competency. Third, we did not assess whether the last clinical encounter was a new patient or an established patient, which may also influence physician behaviors. For established patient, physicians may have known the sexual history, so they did not need to ask these questions again in their last encounter. In this case, it would not necessarily indicate they are not competent. Forth, physicians were recruited from a medical app online, and there may be selection bias because all survey participants were app users. Fifth, this was a cross-sectional study, so no causal relationship can be established. Sixth, we didn’t obtain the information on how the STIs were confirmed by physicians. There was a potential for invalidity of STI diagnosis.

This study expands the limited literature on MSM service providers in China, providing a current perspective of MSM-competent physicians. We observed a diverse sample of physicians from a range of subspecialties and medical institutions in China meeting criteria for competent clinical care for MSM. Most physicians were interested in the training and improving MSM clinical services. More research on physicians’ clinical competency is strongly recommended to provide a more accurate and comprehensive description of MSM-competency. Further research is needed to explore novel methods of engaging physicians in MSM care and developing interventions aimed at physicians in order to improve MSM clinical competency.