Disclosure of male attraction to primary care clinicians by adolescent sexual minority males

Abstract

Introduction:

Adolescent sexual minority males (ASMM) experience higher rates of HIV and other sexually transmitted infections (STIs) relative to their heterosexual peers. Primary care clinicians (PCCs) are well positioned to discuss sexual health and STI prevention with adolescent males; however, ASMM report they are rarely asked about their sexual health, especially with respect to attraction and identity. This study sought to determine variables associated with disclosure of male attraction (“being out”) to a PCC.

Methods:

ASMM (N=206; 14 to 17 years in the United States) completed an online sexual health survey in 2017. We assessed socio-demographics, sexuality, being out to a guardian, and being out to a PCC, and calculated proportions and associations among the variables using univariable (Fisher exact) and multivariable (Firth logistic regression) analyses.

Results:

Only 20% (n=41) of ASMM were out to their PCC even though 53% (n=109) were out to a parent or guardian. ASMM who were out to a parent or guardian were seven times more likely to be out to their PCC (adjusted odds ratio = 6.69, 95% confidential interval 2.69 to 16.60). No other variables were associated with being out to a PCC.

Conclusions:

Among ASMM, the only predictor of outness to a PCC in this study was outness to a parent or guardian, yet only half were out to a parent or guardian.

Policy Implications:

PCCs should proactively and routinely inquire about sexual health and screen adolescent males for same sex attraction and sexual minority identity in order to provide optimal health care.

Introduction

Adolescent sexual minority males (ASMM) experience a range of health disparities in the United States (U.S.). Compared to their heterosexual peers, ASMM have higher rates of HIV and other sexually transmitted infections (STIs), substance misuse, and suicide (Coker et al., 2010).

The American Academy of Pediatrics and Society of Adolescent Health and Medicine recommends that primary care clinicians (PCCs) discuss sexuality with all adolescents (Hagan et al., 2007; Marcell et al., 2017; Society for Adolescent Health and Medicine (SAHM), 2014). In addition, guardians and adolescents also want PCCs to discuss sexuality during visits (Ford et al., 2011). However, research indicates that such discussions are frequently late, heteronormative, incomplete, or absent altogether (Fuzzell et al., 2017). One recent study of ASMM found 68% had a “regular doctor” or PCC, but when asked about discussing sexual health with a provider in the past year, 79% did not disclose sex with male partners, and 71% were never asked about sexual orientation (Mustanski et al., 2020). Only 11% of physicians regularly ask adolescents about attraction and 29% ask about orientation (Kitts, 2010). Using audio recordings of 49 physicians talking with 393 adolescents during actual health maintenance visits, researchers found conversations about sexuality lasted an average of 36 seconds, and 97% of conversations used language that either directly or indirectly assumed heterosexuality (Alexander et al., 2014). Using heteronormative language and failing to discuss sexual attraction, orientation, and identity with adolescents undermines meaningful conversations with ASMM about sexual health, inadvertently exacerbating health disparities among this group.

Inquiring about all aspects of sexuality with adolescents, identifying ASMM in primary care settings, and addressing sexual health with ASMM are essential to providing preventative services to ASMM, including STI screening, condom provision and counseling, and guidance about relationship safety (Marcell et al., 2018). In addition, identifying sexual minority youth allows PCCs to address the unique needs of this group, which have a high level of unmet health needs (Williams & Chapman, 2012). Whereas prior studies have shown disclosure of sexual minority status (being “out”) to a provider is associated with improved screening of and service provision to sexual minority young adults (Singh et al., 2018; Youatt et al., 2017), few studies have assessed ASMM outness to PCCs (Fuzzell et al., 2017). One study found that more than half of 14–17 year old ASMM did not communicate their sexual orientation and sexual health concerns to their PCC due to worries about heterosexist bias (Fisher et al., 2018). Other studies of ASMM reveal that non-disclosure/lack of outness to parents and PCCs is a barrier to receipt of HIV prevention-related care, such as pre-exposure prophylaxis (PrEP) (Macapagal et al., 2020; Moskowitz et al., 2020; Stults et al., 2020).

Whereas the focus of sexual health history taking often focuses on sexual behavior, research demonstrates that sexuality is a fluid process of identity formation that begins before adolescence and encompasses attraction and orientation as well as behavior (Rosario et al., 2006). For example, 28% of gay, lesbian, and bisexual youth changed their self-identified identities over time (Rosario et al., 2006). Because there is a group of ASMM who are attracted to males but may not identify as gay or have had sexual contact with males, PCCs who do not ask about attraction, orientation, and behavior may miss opportunities to identify ASMM and tailor their sexual health counseling accordingly. In addition, recent data suggests age and race/ethnicity may impact outness to PCCs among ASMM (He et al., 2020; Stults et al., 2020).

Few studies have directly assessed factors that are likely to predict outness to a PCC among ASMM. Therefore, for this study, we assessed whether ASMM were out to their PCC about male attraction and explored whether sociodemographic and sexuality characteristics are associated with being out to a PCC.

Methods

A convenience sample of ASMM was recruited online from across the U.S. for a sexual health survey. Study methodology has been described elsewhere (Nelson et al., 2018). Briefly, participants were recruited in June and July 2017 via advertisements and posts on social media (e.g., Instagram, Facebook). Posts were targeted to males in the U.S. who were ages 14 to 17 years of age with a focus on recruiting individuals who may be attracted to males but not necessarily identify as gay or bisexual or be sexually active. Advertisements used images and interests which represented the recommendations of a racially/ethnically diverse youth advisory board, and reflected interests common to ASMM (e.g. King Bach, RuPaul’s Drag Race, Todrick Hall).

Eligibility criteria included: (1) age 14 to 17; (2) cisgender male; (3) self-identify as gay/bisexual, report being sexually attracted to males, or report voluntary past year sexual contact with a male partner; (4) live in the U.S.; and (5) have a personal email address. Potential participants were directed to the study website for screening and consent using REDCap (Harris et al., 2009). Capacity to consent was assessed using four questions that evaluated respondents’ understanding of study procedures, risks, and benefits (Dunn & Jeste, 2001; Procedures for Determination of Decisional Capacity in Persons Participating in Research Protocols, 2003). Respondents who were unable to accurately answer all four questions after three tries were designated ineligible. Those who consented received a unique survey link via email. The survey required an average of 30 minutes (SD = 12) to complete, and remuneration of $15 Amazon.com gift code was provided. To protect against fraudulent entries and multiple enrollments, screening and survey responses were cross-referenced using date of birth, location, sexual activity, and email address (Bowen et al., 2008; Sullivan et al., 2013). All procedures, including a waiver of parental/guardian consent for the survey, were reviewed and approved by the hospital Institutional Review Board.

Measures

Sociodemographic variables included age (continuous), race/ethnicity (non-Hispanic White, non-Hispanic Black or African-American, Hispanic or Latino, mixed race or other); living with guardian (yes, no), urbanicity based on zip code (metropolitan residence, other; University of North Dakota Center for Rural Health, 2014), and U.S. Census region (based on self-report state of residence; U.S. Department of Commerce Economics and Statistics Administration, 2015).

Sexuality variables were adapted from the 2015 Youth Risk Behavior Surveillance System (Kann et al., 2016) and work by Austin, et al (Austin et al., 2007). Questions asked were: (A) Orientation: “How do you identify your sexual orientation?” with options gay, bisexual, heterosexual (straight), queer, other [categorized yes if selecting “gay”, no if other response]; (B) Ever voluntary male sexual contact: “I have had voluntary sexual contact with: (check all that apply)” with options female partners, male partners, and transgender partners [categorized yes, no]; (C) Attraction to males: “I am sexually attracted to…” 1) only men, 2) mostly men, but some women, 3) equally men and women, 4) mostly women, but some men, or 5) only women [categorized yes if responding 1, 2, 3, or 4; no if 5]. Orientation, contact, and attraction variables were highly correlated with each other. For this reason, and because we were interested in exploring differences in outness between (a) ASMM who identify as gay or who had prior male sexual contact and (b) ASMM who only reported male attraction but not gay-identity or prior male sexual contact (Rosario et al., 2006), we created three exclusive categories based on the orientation (A), sexual contact (B), and attraction (C) variables described above. These categories were: 1) gay-identified (yes to A, yes or no to B, yes or no to C), 2) non-gay identified but reporting voluntarily sexual activity with males (no to A, yes to B, yes or no to C), and 3) attracted to males, non-gay identified, and no prior voluntary sexual contact with males (no to A, no to B, yes to C).

Outness was measured using items adapted from prior studies (Fisher et al., 2018; Glick & Golden, 2014), specifically 1) being out to a PCC (“I have spoken to my doctor about my interest in sex with male partners,” categorized yes, no), and 2) being out to at least one guardian (“Have you told (guardian) that you are sexually attracted to other boys/males?” categorized yes, no).

Analysis

Socio-demographic differences by outness to PCC were assessed using Fisher exact tests. Firth logistic regression was used to assess associations between outness to a PCC and the following: sociodemographic characteristics (age, race/ethnicity), sexuality variables, and outness to a guardian. Age, race/ethnicity, outness to guardian, and sexuality variables were included in the multivariable model based on our a priori expectation that these variables would be associated with outness to PCC.

Results

Of the 2,346 potential participants who clicked on the survey link, 2,232 (95%) agreed to the screener and 661 (30%) were eligible. About half of these (n=353, 53%) completed the consent process, agreed to participate, and were sent an email with the survey link. The response rate was 81% (n=287 of the 353 enrolled completed the survey). Eighty (28%) participants were excluded due to internal discrepancies suggesting ineligibility or a potential duplicate. One (0.3%) participant had missing data about outness with a guardian and was excluded, and no participants had missing data about outness to a PCC. This left a final analytic sample of 206 ASMM.

Table 1 summarizes socio-demographic differences by outness to PCC. Participants were 16 years old on average (SD=1.0) and were recruited from all regions of the U.S. (Northeast: n=37, 17%; South: n=58, 29%; Midwest: n=41, 20%; West: n=69, 34%). Nearly half identified as racial or ethnic minorities (n=97, 47%). The vast majority lived at home with their parents (n=191, 93%) and in urban areas (n=169, 87%).

Table 1 -.

Variables associated with being out to a PCC among 14 to 17-year-old sexual minority males in the United States (N = 206)

		Out to a PCC
	Total (N = 206) No. (%)	Yes (n =41) No. (%)	No (n =165) No. (%)	p value
Age: 14	32 (15)	5 (12)	27 (16)	0.683
15	51 (25)	10 (24)	41 (25)
16	68 (33)	12 (29)	56 (34)
17	55 (27)	14 (34)	41 (25)
Race/ethnicity:				0.630
Non-Hispanic White	109 (53)	19 (46)	90 (55)
Non-Hispanic Black	30 (15)	6 (15)	24 (15)
Hispanic or Latino	42 (20)	9 (22)	33 (20)
Mixed race or othera	25 (12)	7 (17)	18 (11)
Living with guardian	191 (93)	36 (90)	155 (94)	0.481
Living within metropolitan area	169 (87)	38 (95)	131 (85)	0.116
Census region:				0.422
Northeast	34 (17)	7 (17)	27 (17)
Midwest	41 (20)	11 (27)	30 (19)
South	58 (29)	8 (20)	50 (31)
West	69 (34)	15 (37)	54 (34)
Any attraction to males	205 (99)	40 (98)	165 (100)	0.199
Gay-identified	136 (66)	28 (68)	108 (65)	0.854
Voluntary sexual contact with male partner(s)	117 (57)	27 (66)	90 (55)	0.220
Identity, behavior, and attraction combined:
Gay-identified	136 (66)	28 (68)	108 (65)	0.334
Non-gay-identified with voluntary sexual contact with males	41 (20)	10 (24)	31 (19)
Attracted to males, non-gay-identified, no voluntary sexual contact with males	29 (14)	3 (7)	26 (16)
Out to guardian	109 (53)	35 (85)	74 (45)	<0.001

^a=Mixed race or Other includes those who answered “yes” to identifying with more than one race, or as “mixed race” (mixed), or identified as American Indian/Alaska Native, or Asian/Pacific Islander.

Almost all ASMM reported male attraction (n=205, 99%). Two-thirds (n=136, 66%) identified as gay. Twenty percent (n=41) reported voluntary sex with males but were not gay identified. Fourteen percent (n=29) reported male attraction but were non-gay-identified and had no voluntary male sexual contact. Approximately one-half (n=109, 53%) were out to a guardian. One-fifth (n=41, 20%) of all participants were out to their PCC.

Compared to ASMM not out to a guardian, those who were out to a guardian had 7 times the odds of being out to their PCC (aOR 6.69, 95% CI 2.69–16.60; Table 2). Outness to a PCC was not associated with any other variable.

Table 2 -.

Associations between sociodemographic, sexuality, and being out to a PCC among 14 to 17-year-old sexual minority males in the United States (N = 206)

	OR [95% CI]	aOR [95% CI]
Age (continuous)	1.18 [0.85, 1.66]	1.04 [0.72, 1.50]
Race/ethnicity:
Non-Hispanic White	ref	ref
Non-Hispanic Black	1.23 [0.46, 3.33]	1.27 [0.43, 3.74]
Hispanic or Latino	1.32 [0.55, 3.14]	0.89 [0.35, 2.32]
Mixed race or othera	1.88 [0.71, 5.01]	1.94 [0.65, 5.84]
Identity, behavior, and attraction combined:
Gay-identified	ref	ref
Non-gay-identified, but voluntary sexual contact with males	1.27 [0.56, 2.86]	1.60 [0.64, 3.98]
Attracted to males, non-gay-identified, no voluntary sexual contact with males	0.50 [0.15, 1.65]	0.75 [0.21, 2.70]
Out to guardian	6.71 [2.75, 16.34]	6.69 [2.69, 16.59]

^a=Mixed race or Other includes those who answered “yes” to identifying with more than one race, or as “mixed race” (mixed), or identified as American Indian/Alaska Native, or Asian/Pacific Islander.

Discussion

In this convenience sample, only one in five ASMM were out to their PCC; thus, the vast majority (80%) of ASMM did not disclose their sexual attraction, orientation, or same sex/gender behavior to their provider. Further, 14% of ASMM reported only male attraction and did not identify as gay or report having male sexual contact. PCC who fail to ask about attraction separately from sexual identity or behavior may not identify vulnerable youth who could benefit from services regarding STIs, substance use, mental health, suicide prevention, and bullying – health needs that affect sexual minority youth at higher rates than their heterosexual peers (Centers for Disease Control and Prevention (CDC), 2018; Coker et al., 2010; Raifman et al., 2020). Outness to a guardian about attraction to male partners increased the likelihood of being out to a PCC, but only about half of the participants were out to a guardian. These findings are similar to a study of sexually active ASMM that found that 29% of participants felt comfortable discussing sexual orientation with their regular pediatric or family practice provider and 63% were out to one or more guardians (Fisher et al., 2018).

Policy makers and providers should consider the following implications of this study. First, PCCs should not assume that ASMM or guardians will initiate conversations about sexuality or disclose sexual minority status; therefore, PCCs should sensitively ask all adolescents about sexual health (Hagan et al., 2007; Marcell et al., 2017; Society for Adolescent Health and Medicine (SAHM), 2014). Normalizing conversations between PCCs and all youth about sexuality is important. To allay provider and adolescent discomfort, providers might introduce their inquiry by saying that sexuality is an expected part of human development, identity formation, and health (Fuzzell et al., 2017). Improving the quality of these conversations for sexual minority youth is vital given evidence that sexual minority youth often receive negative messages from media, peers, and adults stigmatizing their identities and attractions, with resulting negative physical and mental health effects (Meyer, 2003). Programs that prepare youth-serving providers and staff—including physicians, nurse practitioners, physicians’ assistants, nurses, and other staff—should include curricular content, simulation practice, and other training opportunities to improve the confidence and competence around providing health care to sexual minority youth. For example, the Society of Adolescent Health and Medicine has recommended such competence among all providers who care for youth, which would include skills such as “understanding of adolescent sexuality development, the ability to identify mental health issues related to either the coming-out process or victimization, and familiarity with physical and sexual health issues related to sexual orientation or gender identity.” (Society for Adolescent Health and Medicine (SAHM), 2013)

Second, if PCCs do not regularly ask adolescents about all three aspects of sexual orientation—attraction, identity, and behavior—they will miss ASMM who: 1) are attracted to males but do not identify as gay, 2) have not had male sexual contact, and 3) have identities, behaviors, and attractions that change over time. This is a lost opportunity for an open conversation between PCCs and ASMM about sexuality, healthy relationships, mental health, and other key topics that contribute to healthy development of this underserved population. Indeed, a systematic review found that even brief discussions about sexuality are effective in increasing condom use and decreasing rates of STIs (Cooper et al., 2014). A survey of sexual minority youth found that most respondents would welcome these discussions, and the modal response to a question about how best to improve their own comfort around these discussions was “just ask me” (Meckler et al., 2006). Moreover, omitting sexual health discussions may undermine the patient-physician relationship, inadvertently alienate ASMM patients, and exacerbate health disparities among ASMM.

To address this issue, experts have developed guidance on addressing sexual health for practicing PCCs (Fuzzell et al., 2017; Robinson et al., 2002) as well as programs that train physicians (Criniti et al., 2014; Rubin et al., 2018) and nurse practitioners (Rowniak & Selix, 2016). Improved training of future PCCs, continuing education for practicing PCCs, and implementation of routine assessment of sexual health in primary care settings will allow PCCs to fulfill their key role in supporting the sexual health of all people, and sexual minority youth in particular. Given evidence about the value of primary care and regular visits for adolescents (Hagan et al., 2007; Marcell et al., 2017; Society for Adolescent Health and Medicine (SAHM), 2014), the health care system has missed an opportunity to provide appropriate sexual health care to both ASMM who are not out to their PCC, as well as those who do not have a PCC.

Finally, our findings support parents of adolescent males creating spaces for open communication about sexual health. We found outness to PCCs to be strongly associated with outness to parents—while the directionality of this association was not assessed in this study, prior work indicates that ASMM often come out to parents before providers (D’amico et al., 2015). Evidence-based programs and resources to assist parents in having these discussions in an open and non-judgmental way are rare but growing in number (Widman et al., 2019), and an important element of these discussions is for parents to encourage their children to discuss sexual health with their PCC.

Our findings should be interpreted mindfully given the following limitations. First, this is a single, cross-sectional study with a convenience sample of ASMM conducted in the U.S, which limits generalizability. Second, we asked all participants about their disclosure of male attraction to a PCC but did not assess whether participants had a PCC or not, any information about their most recent visit with a PCC, the quality of their PCC relationship, other interactions with healthcare providers or staff, or attitudes around disclosure of outness. Future research should assess the PCC-youth relationship more thoroughly to understand how these intricacies may related to youth being out with their PCC or not and related provision of services. For this study, we did not include condomless sex or HIV/STD testing. Instead, we focused on sociodemographic variables and how these may predict outness to PCCs. Nonetheless, these behaviors are worthy of investigation in future research.

In summary, we found few ASMM were out about their sexuality to their PCC, and only half were out to their parents. To provide optimal health care for this group and all adolescents, PCCs should proactively, routinely, and sensitively inquire about sexual health with all adolescents, including gender identity, attraction, orientation, and behaviors. Universal assessment will allow PCCs to establish trust, create safe spaces for disclosure of sensitive information, and provide services to help decrease the health disparities ASMM experience during a critical period in their lives.