Openness about sexuality predicts deferral policy noncompliance among recent MSM (men who have sex with men) blood donors: An exploratory analysis

Abstract

Background

Blood service providers use deferral policies to reduce the risk of transfusion‐transmitted infections, but policy effectiveness depends on donors' honesty in disclosing risk behaviors. Identifying specific social factors within men who have sex with men (MSM) may provide insight into noncompliance with sexual behavioral deferral criteria.

Methods

We identified a sample of 136 recent blood donors from a large behavioral surveillance survey of MSM in New Zealand. Univariate analyses were used to identify factors associated with self‐reported noncompliance before a two‐step hierarchical regression assessed whether MSM‐related social factors added to the prediction of noncompliance, compared to only considering background characteristics.

Results

Incorporating the MSM‐related social factors significantly enhanced the model fit, explaining 23.2% additional variance in noncompliance (Nagelkerke R ² = 0.331, p = .002). Only MSM who were more open about their sexuality had increased odds of noncompliance (Odds ratio 5.25, 95% Confidence Interval 1.78–15.48, p = .003). Full‐time employment remained a predictor of lower noncompliance in the final model (OR 0.19, 95% CI 0.05–0.69, p = .012).

Conclusion

This exploratory evidence suggests that blood service providers should consider the broader social context, particularly openness about sexuality, in understanding noncompliance with time‐based sexual behavior donor deferral criteria. This “outness” in MSM donors likely reflects confidence in making disclosure decisions based on their perceived HIV risk, challenging the notion that noncompliance necessarily arises from discomfort or lack of knowledge about policies. Future research should explore the gap between perceived risk and policy understanding to better address MSM donors' complex decision‐making processes.

Abbreviations

GBM

gay, bisexual, and other men who have sex with men

MSM

men who have sex with men

NZ

New Zealand

TTI

transfusion‐transmissible infection

1. INTRODUCTION

A careful selection of donors is required to ensure blood safety. Despite screening for transfusion‐transmissible infections (TTIs, e.g., HIV), there is a small but non‐zero probability that undiagnosed infections remain undetected. ¹ To mitigate this risk, deferral policies act as a pragmatic tool to exclude higher‐risk individuals. However, the utility of such policies relies on the likelihood of donors honestly and accurately disclosing behaviors seen as posing a potential risk to the blood supply: what blood services refer to as “compliance.” Since noncompliant individuals increase the risks of TTIs being missed and transfused to recipients, understanding the factors predicting noncompliance is a public health priority.

The recent adoption of gender‐neutral policies has expanded eligibility for blood donation to include more men who have sex with men (MSM). However, unique social pressures may deter MSM from disclosing relevant information during pre‐donation behavioral screening, challenging compliance and blood safety. Anonymous surveys of confirmed MSM donors revealed that noncompliant individuals were hesitant to disclose sexual activity and, by proxy, sexual identity, due to stigma or privacy concerns. ² , ³ , ⁴ Such concerns are likely prominent in donation contexts where revealing one's sexual identity could be uncomfortable or unsafe (e.g., in front of family or colleagues).

While blood services can implement processes to encourage disclosure of sensitive behaviors, the social and political impact of historical MSM exclusion policies on noncompliance has been overlooked. Many MSM view exclusion policies as discriminatory, and some donate despite being ineligible. ³ , ⁵ Noncompliance may represent a form of “protest” against exclusionary policies, ³ or reflect the belief that policies are unscientific, particularly if potential donors perceive their HIV risk as low. ⁶ , ⁷ , ⁸ Although data are lacking, it is possible that being more embedded in communities where negative views of deferral policies are common may predict noncompliance.

This exploratory report examines how MSM identity, social connectedness, and attitudes toward the deferral policy and blood services predict noncompliance with a newly introduced 3‐month deferral policy among recent MSM donors.

2. METHODS

2.1. Survey and recruitment

The Sex and Prevention of Transmission Study (conducted from April to August 2022) was a voluntary, confidential, cross‐sectional online survey on blood donation and HIV‐related behaviors in New Zealand (NZ). Participants were eligible if they were 16 or older, living in NZ, and identified as a gay, bisexual, or non‐heterosexual man, or had ever had sex with a man. Recruitment involved social media, gay dating apps, community mailing lists, and posters in public and LGBTQ‐friendly spaces. Consent was obtained before completing the survey on Salesforce/SurveyTitan. The study was approved by the NZ Health and Disability Ethics Committee (HDEC 2021 EXP 11450).

2.2. Sample

Of 3838 survey participants, 136 donated blood during 2021 and 2022 (i.e., since the NZ MSM deferral policy was reduced to 3‐months) and were eligible for this analysis. Donors were asked to recall their most recent donation and report if they had sex with a man within 3 months before donating (yes/no). Noncompliance was defined as those who responded yes (n = 33), while the remainder were classified as compliant (n = 103).

2.3. Measures

General background information included demographics (age, ethnicity, employment status, highest educational attainment) and self‐reported donor status (first time donor, repeat donor).

MSM social identity was captured through two questions: “How much of your free time is spent with other gay, bisexual, or other MSM?” (dichototomised to: A lot/Not a lot) and “How open are you about your sexual identity?” (dichotomized to: Out to most/Not out to most). Self‐reported sexual identity was dichotomised as gay‐identifying only versus not (bisexual and other).

Participants rated three attitudinal constructs related to blood donation, each forming a reliable scale with acceptable internal consistency (α > .600). The first measured general attitudes toward the civic importance of donating (α = .746). The other two were specific to MSM: negative views of the deferral policy as discriminatory toward MSM (α = .839) and positive attitudes toward the blood service regarding their treatment of MSM (α = .701). All items were rated on a 1–5 Likert scale (Strongly disagree–Strongly agree), and mean scores were used for analysis.

2.4. Analytic strategy

Univariate tests (chi‐square and t‐tests) were used to assess differences in all variables between compliant and noncompliant donors.

A two‐step hierarchical logistic regression was then performed. Model 1 included donor background characteristics (age, ethnicity, employment, education, donor status, and civic importance of blood donation). Model 2 added social factors more relevant to MSM (openness about sexuality, community attachment, sexual identity, and attitudes toward the deferral policy and blood services). Changes in model fit and variance explained (Nagelkerke R ²) helped identify key factors influencing noncompliance.

All results in Table 1 represent the odds of being assigned to the noncompliant group given the nonreferent groups.

TABLE 1.

Sample characteristics stratified by sexual compliance classification and multivariate logistic regression predicting noncompliance in MSM donors (n = 133).

				Model 1		Model 2
Variable	Compliant (n = 106)	Not compliant (n = 33)	Test statistic	Odds ratio	95% CI	Odds ratio	95% CI
Donor's background characteristics
Age (years) a	28.22 (9.68)	26.83 (9.92)	0.68	1.01	(0.96–1.06)	1.02	(0.96–1.08)
Ethnicity
NZ European	74	23	0.06	1.29	(0.46–3.59)	.911	(0.29–2.90)
Not NZ European	29	10		Ref.		Ref.
Employment status
Full‐time	54	11	5.52*	0.36*	(0.13–0.99)	0.19*	(0.05–0.69)
Not full‐time	34	19		Ref.		Ref.
Education attainment
Tertiary	50	11	2.34	0.64	(0.23–1.78)	0.77	(0.25–2.37)
Non‐tertiary degree	53	22		Ref.		Ref.
Donor experience
Repeat donor	84	29	0.56	0.78	(0.21–2.86)	0.55	(0.13–2.38)
First time	18	4		Ref.		Ref.
Civic importance of blood donation a , b	4.21 (0.86)	4.32 (0.77)	−0.64	1.17	(0.67–2.04)	0.59	(0.23–1.51)
Donor's MSM‐related characteristics
Outness
Out to all or almost all people	24	18	10.99***	–		5.25**	(1.78–15.48)
Not out to all or almost all people	66	12		–		Ref.
Community attachment
A lot of time spent with other MSM	50	23	4.50*	–		1.43	(0.51–4.00)
Not a lot of time spent with other MSM	53	10		–		Ref.
Sexual identity
Gay‐identifying	60	21	0.30	–		1.41	(0.48–4.12)
Not gay‐identifying	43	12		–		Ref.
Negative attitudes toward the MSM deferral policy a , b	4.11 (1.00)	4.47 (0.70)	−2.26*	–		1.76	(0.60–5.13)
Favorable attitudes toward the blood service a , b	2.34 (0.86)	1.91 (0.99)	1.89*	–		0.50 †	(0.24–1.05)

Note: Some cells do not add up to n = 136 due to missing cases.

^a Presented as means (standard deviations).

^b Measured on a Likert‐type scale (1 = Strongly disagree, 5 = Strongly agree).

^† p < .10;

^* p < .05;

^** p < .01;

^*** p < .001.

3. RESULTS

3.1. Univariate analyses characterizing the sample

Counts, test statistics, and odds ratios are presented in Table 1. The average age was 27.9 years, albeit positively skewed (median: 25, range: 17–66). Of 136 donors, 87% were repeat donors (n = 113), and the frequency of donation was not associated with noncompliance (p = .455). Tests for association across background factors only showed a link between employment and compliance classification (p = .019).

Chi‐square tests showed associations between donor noncompliance and greater openness about sexuality (p < .001) and community attachment (p = .034). With respect to attitudes, noncompliers rated the MSM deferral policy more negatively (p = .028) and viewed the blood services less favorably (p = .017) in comparison to compliant donors. Full table of correlations provided in Table S1.

3.2. Hierarchical multivariate logistic regression predicting noncompliance

Including background characteristics alone in Model 1 was not significant (Nagelkerke R ² = 0.099, p = .233). However, noncompliance was less likely when individuals were in full‐time employment (Odds ratio [OR] 0.36, 95% Confidence Interval [CI] 0.13–0.99, p = .049).

Model 2 produced a significant model (−2 Log Likelihood = 101.503, Nagelkerke R ² = 0.331, p = .002), reflected in a 0.232 increase in Nagelkerke R ². In this full model, individuals who were more open about their sexuality had higher odds of noncompliance (OR 5.25, 95% CI 1.78–15.48, p = .003). More favorable ratings of the blood services marginally predicted lower odds of noncompliance (OR 0.50, 95% CI 0.24–1.05, p = .066) while being in full‐time employment remained a predictor of lower noncompliance (OR 0.19, 95% CI 0.05–0.69, p = .012).

4. DISCUSSION

Our findings suggest broader MSM social factors may be important when assessing donor compliance, particularly when prospective donors are asked to disclose recent male‐to‐male sexual partners during the pre‐donation process.

A strength of this report lies in the sampling approach that identified MSM donors in a diverse community sample of MSM rather than drawing from donor databases, ⁶ , ⁹ , ¹⁰ , ¹¹ , ¹² in which response rates are typically low and/or participants self‐selected because MSM (or certain types of MSM) may systematically opt out of participation.

Surprisingly, being more open about one's sexuality in one's private life (i.e., being “out”) was associated with greater noncompliance among MSM donors. Possible interpretations are offered below.

First, greater openness about one's sexuality might reflect greater understanding of personal sexual health. A previous report found that MSM who are more open about their sexuality had more recently tested for HIV and sexually transmitted infections. ¹³ Given that HIV testing is free and widely accessible in NZ, it is unlikely that noncompliance in this group is motivated by the desire to access free HIV testing. As such, greater “outness” in this context may index an individual's confidence or comfort in deciding whether to disclose sexual behavior. Such a decision is likely based on the interplay between an understanding of their own HIV risk and their perceived level of risk according to the deferral policy. A discrepancy between subjective and policy‐indicated risk may explain why some donors, notably those in monogamous relationships, ³ choose not to disclose behaviors they consider low risk. ³ , ⁶ , ⁷ , ⁸

Alternatively, being “out” may reflect a stronger social connection with the wider gay community. This may heighten negative perceptions of deferral policy, fueling a sense of injustice for those who see it as discriminatory. Consequently, some noncompliant donations may occur as a form of “protest” against the perceived unfairness of the policy. ³ , ⁴

The study design, however, prevents us from drawing strong conclusions about the specific role of MSM “outness” in donor noncompliance and its meaning. While other MSM‐related variables were significant in univariate analyses, the heavily skewed but overlapping confidence intervals suggest these exploratory analyses struggled for power. It would be premature to dismiss the importance of community connectedness and policy‐specific attitudes in understanding what motivates noncompliance among MSM donors.

Nevertheless, our findings offer an alternate perspective on MSM noncompliance that can help guide future empirical research. While a recent study found that questions about sexual health histories are among the least likely to be answered honestly in a donor health questionnaire, ¹⁴ our results would suggest that for MSM, noncompliance unlikely stems solely from discomfort in disclosing personal behaviors, ² , ³ , ¹⁵ or a lack of knowledge about HIV risk and deferral policy guidelines. ³ , ⁶ Instead, MSM may critically evaluate deferral policies and make compliance decisions based on their personal assessment of HIV risk, ³ , ⁶ , ⁷ , ¹⁶ rather than accepting how blood services define “risk.” This may suggest that MSM donors actively evaluate contemporary HIV prevention and risk reduction information, rather than passively consuming it, when making decisions about disclosing sexual behavior.

In conclusion, these exploratory findings suggest the need for strategies that go beyond education to address noncompliance among MSM donors. Approaches that consider broader decision‐making processes, including the influence of social factors and openness about sexuality, are essential. For example, blood services may benefit from improving communication about the rationale for deferral questions, and by engaging more directly with MSM communities to understand how policies are interpreted by this group. Future research should explore the gap between MSM donors' understanding of deferral policies and their perceived risk, as well as the experiential and social factors that shape disclosure decisions.

CONFLICT OF INTEREST STATEMENT

The authors have disclosed no conflicts of interest.

ETHICS STATEMENT

The study was approved by the New Zealand Health and Disability Ethics Committee (Approval number: HDEC 2021 EXP11450). Written informed consent was obtained from each participant for study participation and data publication.

Supporting information

Table S1. Spearman's rank correlation coefficients and p‐values (two‐tailed) among all variables.

Sriamporn KT, Consedine NS, Saxton PJW. Openness about sexuality predicts deferral policy noncompliance among recent MSM (men who have sex with men) blood donors: An exploratory analysis. Transfusion. 2025;65(9):1586–1591. 10.1111/trf.18352